Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (3): Disorders of Consciousness

In order to better understand the decision-making issue, I have, in the previous posting, described the hospital ethics committee form and function since the committee could be involved in the process. Another element of the issue to understand is a current description and definition of the various disorders of consciousness that determine the conclusion that the patient is incompetent to participate in his or her decision-making. Also the prognosis of the specific disorder may well affect the decision made by others.

The following Glossary of Disorders of Consciousness is taken from the “State Initiatives in End of Life Care” Oct. 2004, Issue 22 published by Center for Practical Bioethics

Brain Death: The permanent absence of all brain functions, including those of the brain stem (which controls basic function like reflexes and breathing).
Coma: Patients in coma lack both wakefulness and awareness. Comas are typically transient: patients recover, die or evolve in some other state of impaired consciousness.
Vegetative States: The Multi-Society Task Force on Persistent Vegetative State (PVS), which included representatives from many of America’s most prestigious neurology associations, has defined the vegetative state as a condition of complete unawareness of self and environment, accompanied by sleep-wake cycles and either total or partial preservation of areas of the brain controlling automatic functions like heart activity and reflexes. PVS patients may cry or smile but these actions are reflexive and do not reflect true awareness.
“Persistent” versus “Permanent” Vegetative States: A vegetative state is considered “persistent” after one month. Vegetative states are considered “permanent” after one year if caused by traumatic injuries such as a blow to the head; non-traumatic vegetative states caused, for example, by oxygen deprivation to the brain are considered permanent after three months. Guidelines for children differ.
Minimally Conscious States: Patients in minimally conscious states posses sleep-wake cycles and limited, inconsistent but definite awareness of self and environment (e.g., avoiding unpleasant stimuli, uttering intelligible sounds or reaching for objects in a way that adjusts for their size and location).
Dementia: A degenerative neurological disorder characterized by progressive loss of all cognitive functions with some arousal mechanisms remaining normal. Patients with advanced dementia who lose self-awareness and learned behavior often evolve into minimally conscious states and,at times,into vegetative states.

It should be emphasized that in the case of brain death, the patient is by law considered dead and there are no treatment decisions to be made.
Coma, if produced by administration of CNS depressants as well as various metabolic causes, can be fully reversible.
The “minimally conscious state” is a more recent diagnostic entity and there is still professional controversy about this diagnosis.
Now we will go on to consider possible approaches to the ethical issue of Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates. ..Maurice.