Conscious in a Vegetative State?
A Critique of the PVS Concept

The 'Persistent Vegetative State' (PVS) has established itself as an apparently discrete medical condition. This book traces the origins of perceptions about PVS and submits these to critical examination. It comes to the conclusion that inadequate attention has been paid to acknowledging what is not known about affected individuals.

The book will be of interest to philosophers, medical graduates and neuroscientists but is also intended to remain accessible to the general reader with an interest in the wider implications of trends in medical thinking for attitudes towards many classes of patient. It has an extensive bibliography and will be of specific interest to bioethicists and lawyers with professional interests in PVS.

Contents.- Acknowledgements.- Introduction.
Chapter 1: History and Context of the Persistent Vegetative State.
1.1. Twenty-five years on: an idea.- 1.2. Responses to an idea.- 1.3. The naming of PVS 5.- 1.4. Pre-existing names.- 1.5. Perceptions engendered by a name.- 1.6. The interface between PVS and brain death.- 1.7. Revising brain death: implications for PVS.- 1.8. Semantic implications.- 1.9. Evolution of the title.- 1.10. Alive or dead?.- 1.11. Dying for how long? An exercise in terminal semantics.- 1.12. Artificial hydration, nutrition and semantics.- 1.13. PVS and the right to die movement.- 1.14. Utilisation of PVS patients.- 1.15. Personhood and PVS.
Chapter 2: The Pathological Basis of Vegetative States.
2.1. Interpretation of the pathological features of patients in vegetative states.- 2.2. Early pathological reports of patients in a vegetative state.- 2.3. Neuropathological features of two defining cases of persistent vegetative state.- 2.4. Neuropathological reports of series of patients in vegetative states.- 2.5. Neuropathological delineation of the PVS from the locked-in syndrome.- 2.6. Effects of medical management on PVS pathology.- 2.7. Deafferentation as a factor impeding assessment of conscious status.- 2.8. From the individual to the general: perceptions of typical PVS neuropathology and personhood.- 2.9. Recapitulation.
Chapter 3: Authoritative Statements.
3.1. Authoritative statements and guidelines.- 3.2. The American Academy of Neurology (A.A.N.) guidelines.- 3.3. The American Medical Association (A.M.A.) report.- 3.4. The American Neurological Association (A.N.A.) statement.- 3.5. The Multi-Society Task Force (M.S.T.F.) on PVS consensus statement.- 3.6. Other U.S. reports.- 3.7. U.K. statements.- 3.8 Recapitulation.
Chapter 4: Consciousness
4.1. Relevance of studies of consciousness to its definitional absence in PVS.- 4.2. Terminology.- 4.3. Vigilance: attention: habituation.- 4.4. Neuroanatomical and neurophysiological aspects of consciousness.- 4.5. Communication.- 4.6. Unconscious mental activity.- 4.7. Personhood and PVS.- 4.8. Recapitulation.
Chapter 5: Sentience.
5.1. Statements on sentience from authoritative sources.- 5.2. Assessing sentient status - individual patients' experience.- 5.3. Assessing sentient status - neuroanatomical requirements.- 5.4. Assessing sentient status - clinical tests.- 5.5. Responses of others to the possibility of retained or regained sentience on the part of a patient in a PVS.- 5.6. The use of analgesic agents in managing PVS patients.- 5.7 Recapitulation.
Chapter 6: Electrophysiological and Imaging Studies of Patients in Vegetative States.
6.1. The electroencephalogram (EEG).- 6.2. Somatosensory evoked potentials (SEP).- 6.3. Imaging of the brain.- 6.4. Structural imaging: computed tomography (CT) scanning.- 6.5. CT indications of brain atrophy in neurologically intact subjects with anorexia nervosa.- 6.6. Functional imaging: cerebral blood flow.- 6.7. Functional imaging: magnetic resonance.- 6.8. Functional imaging: positron emission tomography (PET): the first study of patients in a PVS.- 6.9. The equivalence of PVS and anaesthesia?.- 6.10. The inconsistency between level of anaesthesia and depression of cerebral metabolism.- 6.11. Subsequent PET studies of patients in a PVS.- 6.12. Inter-subject variation in PET-calculated cerebral metabolic rates.- 6.13. PET assessment of changes in cerebral metabolic rate during development.- 6.14. Sedatives and PET-calculated cerebral metabolic rates.- 6.15. Influence of brain atrophy on brain metabolism studies.- 6.16. Location of lesions in vegetative patients using PET.- 6.17 Recapitulation.
Chapter 7: An Analogy between Anaesthesia and the Persistent Vegetative State.
7.1. The issue of awareness under anaesthesia at the time of the M.S.T.F. statement.- 7.2. Inferences about unconscious subjects from study of anaesthesia.- 7.3. Research protocols in the study of awareness under anaesthesia.- 7.4. Type and depth of anaesthesia.- 7.5. Positive suggestion under anaesthesia.- 7.6. Emotional content of stimulus.- 7.7. Amnesia following anaesthesia and unconsciousness.- 7.8. Recapitulation.
Chapter 8: Diagnosis and Misdiagnosis of Vegetative States.
8.1. The place of guidelines.- 8.2. Probability and prediction.- 8.3. Frequency of misdiagnosis of PVS.- 8.4. Diagnosis in court.- 8.5. The ultimate misdiagnosis - locked-in syndrome.- 8.6. Implications of a misdiagnosis of locked-in syndrome for patient management.- 8.7. Recapitulation.
Chapter 9: Emergence from a Vegetative State.
9.1. Frequency of emergence from PVS.- 9.2. Individual cases of emergence: medical literature.- 9.3. Emergence in the non-medical press: a cluster of cases.- 9.4. Recognition of emergence.- 9.5. Recapitulation.
Chapter 10: A Perspective of Disability.
10.1. Assessments by the non-disabled of the wishes of those with a disability.- 10.2. Perceptions of non-disabled medical attendants about people with severe neurological damage.- 10.3. Family views about severely disabled members.- 10.4. Patient views.- 10.5. The remarkable Jean-Dominique Bauby.- 10.6. Treatment preferences of severely disabled people.- 10.7. Quality of life issues.- 10.8. The question of indignity.- 10.9. Social isolation.- 10.10. Depression.- 10.11. Dependency.- 10.12. Recapitulation.
Chapter 11: Positive Management or an Exercise in Futility?
11.1. Attitudes towards management of PVS.- 11.2. A rehabilitation approach.- 11.3. Avoiding complications.- 11.4. Nutrition.- 11.5. Oral versus tube feeding.- 11.6. Nutrition and neuronal multiplication.- 11.7. Sedation and recovery from brain injury.- 11.8. Carers - the family role.- 11.9. Care of the carers.- 11.10. Active intervention to interrupt the vegetative state.- 11.11. The influence of prognostic negativity.- 11.12. Establishing communication.- 11.13. The issue of futility.- 11.14. Who determines futility?.- 11.15. Futility and resource allocation.- 11.16. Is maintenance without recovery a futile goal?.- 11.17. Recapitulation.
Chapter 12: Thirst.
12.1. Thirst in the context of PVS.- 12.2. Sources of information about capacity for thirst.- 12.3. Basic neuroanatomy and neurophysiology.- 12.4. Dehydration in healthy volunteers.- 12.5. Adipsia and hypodipsia.- 12.6. Dehydration in terminally ill patients.- 12.7. Experimental studies of thirst in animals.- 12.8. Relief of thirst sensation without correction of dehydration.- 12.9. Recapitulation.
Chapter 13: Withdrawal of Hydration and Nutrition from Patients in Vegetative States.
13.1. From ventilator disconnection to withdrawal of hydration and nutrition.- 13.2. Withdrawing options.- 13.3. Acts versus omissions.- 13.4. Withholding versus withdrawing.- 13.5. Care versus cure.- 13.6. Tube feeding - nursing care versus medical treatment.- 13.7. Is retention of the capacity for oral feeding significant?.- 13.8. The cause of death after withdrawal of hydration and nutrition.- 13.9. Clinical course following withdrawal of hydration and nutrition.- 13.10. Analgesia and sedation during withdrawal of hydration and nutrition.- 13.11. Making the decision to withdraw hydration and nutrition.- 13.12. Differing roles for families in decision-making.- 13.13. A postscript on decision-making outcomes.- 13.14. Recapitulation.
Chapter 14: Some Economic Considerations.
14.1. Allocation of health-care resources within a social contract.- 14.2. Allocation and reallocation of resources to patients following a PVS diagnosis.- 14.3. Economic implications of varying intensity of care of PVS patients.- 14.4. Family implications.- 14.5. Global costs of PVS to health care systems.- 14.6. Costs of caring for PVS patients in a specialised facility.- 14.7. Prevalence of PVS.- 14.8. Recapitulation.
Chapter 15: Vegetative States in Court.
15.1. PVS court cases as a representative sample of PVS.- 15.2. The use of advance directives in PVS cases.- 15.3. Surrogate decision-making.- 15.4. Interests as the basis for decisions.- 15.5. Legal consideration of life-support systems.- 15.6. PVS in continental European courts.- 15.7. The UK test case: Airedale NHS Trust v Bland.- 15.8. Medical advances as a source of new ethical problems.- 15.9. Tube v mouth: medical v non-medical procedures.- 15.10. Whatever happened to intent?.- 15.11. The Bland case as a precedent.- 15.12. Publication and patient confidentiality.- 15.13. Incidence of PVS court cases after Airedale NHS Trust v Bland.- 15.14. Entrenchment of PVS as a single entity.- 15.15. Whose interests?.- 15.16. Time for consideration.- 15.17. Legal euphemisms.- 15.18. What was the question addressed by the courts in Airedale NHS Trust v Bland?.- 15.19. Recapitulation.
Chapter 16: Continuing Unresponsiveness in the Future.
16.1. A more objective nomenclature is required.- 16.2. Possibilities for prevention of PVS should be explored.- 16.3. Policy formulation should be responsive to adequately informed community input.- 16.4. Neuro-rehabilitation should be instituted earlier after brain injury.- 16.5. Diverse medical and paramedical skills are required in the management of patients who remain unresponsive after brain injury.- 16.6. Resources should be provided for specialised facilities which are likely to have a higher rehabilitation success rate.- 16.7. Patients do better when fed.- 16.8. Research with patients in vegetative states is needed to improve management.- 16.9 In conclusion.
References.- Index.