“Clarifying” the mystery of severe brain injuries should never be an excuse to starve and dehydrate patients

By Dave Andrusko

Periodically, the popular press will pick up on something almost as if it were a sudden revelation. Flash! [fill in the blank]. That is the typically the case with the ‘discovery’ that some severely brain-injured patients who survive the initial trauma have been misdiagnosed.

The medical staff concludes that patient “A” is so badly damaged they will never “wake up.” The counsel is (in that ugly, dehumanizing phrase) to “pull the plug.” And then, lo and behold, the patient does become responsive, most often because the family refuses to be bullied.

The misdiagnosis has customarily been two-fold: What condition the patient actually is in (coma, persistent vegetative state, or minimally conscious) and the likelihood that they will come out of it.

Adding drama and urgency is the more recent genuine discovery that the patient has been hearing and processing all along!

And now two articles in one week. The first–a more general overview –appeared in today’s Wall Street Journal. “Brain Stimulation May Give Hope to Coma Patients,” by Patricia Churchland, described as a neurophilosopher.

The second, “How One Brain Came Back From Unconsciousness,” is by Stephen S. Hall, and deals with one young man who was in a horrific accident and whose chances to survive, let alone anything else, seemed slim and none.

As the title suggests, Mrs. Churchland is largely almost exclusively talking about coma. She does a very nice job explaining the basic breakdown and how neurologists are attempting to compensate for the damage. She writes

A head injury damages the circuitry of the arousal system. Hemorrhages—that is, bleeding—are a major culprit. The pressure of blood in a closed skull can crush the delicate nerve fibers. Normally, to wake us up, the brainstem boots up the central thalamus. In some patients with minimal consciousness, disrupted wiring means the brainstem’s “wake up” signals cannot reach the central thalamus, and thus it stays quiescent. The patient’s brain is stuck in unconsciousness.

Some neurologists, such as Nicholas Schiff at Weill Cornell Medical College in New York, have hoped to compensate for the missing signals by directly stimulating the central thalamus. Research with animal models has suggested this could work in humans to restore consciousness.

Churchland’s conclusions are not as optimistic as they could have been. More important (as perhaps follows from of her gloomier assessment) she ends her essay talking about “double-digit billions” in annual costs for patients in minimally consciousness states, in coma, or in a vegetative state, a figure that could not possibly be correct.

More ominously, Churchland talks about only “modest” “quality of life” improvements “for some” using deep brain stimulation. Her last sentence is

Research will soon clarify which patients stand to benefit.

Really? If you follow the research, the overarching conclusion is that what was thought to be dogma proved to be incorrect.

And what if patients don’t “stand to benefit”? Churchland doesn’t say, but others are quick to offer a ‘solution’: starve them to death or kill them more quickly.

Stephen S. Hall’s very in-depth, very long story about Dylan Rizzo is no Pollyanna account, but it is a corrective to Churchland’ more pessimistic assessment. If you have time, please also read “People with severe dementia should be starved and dehydrated to death to save money says BMJ editorial” which is posted at Monday’s NRL News Today.

Churchland’s story is a reminder that teenagers and young adults who are injured in crashes do recover from brutal brain injuries. By contrast an older person with severe dementia will not recover his or her mental faculties.

But in either case, you don’t take away their food and fluids. That path leads to madness.

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