Persistent Vegetative State, or PVS, is not based on science. PVS was concocted to accomplish the stoppage of medical treatment. In a similar manner and before PVS, “brain death” was conjured to get beating hearts and other vital organs for transplantation.
The following is a list of medical studies which point to the inaccurate nature of a PVS diagnosis:
1. Brain Inj. 2009 Feb;23(2):163-6. “Late recovery from post-traumatic vegetative state.”
Sancisi E, Battistini A, Di Stefano C, Simoncini L, Simoncini L, Montagna P, Piperno R. Department of Neurological Sciences, University of Bologna, via Ugo Foscolo, Bologna, Italy.
AIM: Late recovery of consciousness after 12 months in vegetative state is very rare and is almost invariably associated with severe disability. The aim of this study was to report that late recovery with moderate disability is possible, even after several months in vegetative state. CASE REPORT: This study describes the case of a 22-year-old male student who recovered consciousness from vegetative state 19 months after a traumatic brain injury which had occurred in December 2000. A further slow recovery of motor and cognitive functions up to a moderate disability was observed over 7 years after the brain injury. The patient now lives in the community, speaks, walks and undertakes daily living as well as outdoor leisure activities independently, has resumed his previous university studies and has a part-time non-competitive job. CONCLUSIONS: This case demonstrates that attaining a condition of independent living is possible even after more than 1 year of post-traumatic vegetative state, with an improvement of motor and cognitive functions that can continue for years. Cranioplasty and long-term rehabilitation programmes may be among the variables potentially influencing this unexpected recovery.
PMID: 19191095 [PubMed – indexed for MEDLINE]
2. Brain. 2007 Oct;130(Pt 10):2494-507. Epub 2007 Sep 7. “Do vegetative patients retain aspects of language comprehension? Evidence from fMRI.” Coleman MR, Rodd JM, Davis MH, Johnsrude IS, Menon DK, Pickard JD, Owen AM. Impaired Consciousness Study Group, Wolfson Brain Imaging Centre, University of Cambridge, UK.
Comment in:
Brain. 2007 Oct;130(Pt 10):2482-3.
A diagnosis of vegetative state is made if a patient demonstrates no evidence of awareness of self or environment, no evidence of sustained, reproducible, purposeful or voluntary behavioural response to sensory stimuli and critically no evidence of language comprehension. For those patients who retain peripheral motor function, rigorous behavioural assessment is usually able to determine retained function.
However, some patients do not retain the ability to respond overtly to command and it is becoming increasingly accepted that assessment of these patients should include techniques, which do not rely on any ‘motor action’ on the part of the patient. Here, we apply a hierarchical functional magnetic resonance imaging (fMRI) auditory processing paradigm to determine the extent of retained language processing in a group of 14 aetiologically heterogeneous patients who met the diagnostic criteria for either the vegetative state (n = 7), the minimally conscious state (n = 5), or who were in a severely disabled condition having emerged from a minimally conscious state (n = 2).
Three different levels of speech processing were assessed: (i) Low-level auditory responses were measured using a contrast between a set of auditory stimuli and a silence baseline; (ii) mid-level speech perception processing abilities were assessed by comparing intelligible speech to unintelligible noise stimuli and (iii) high-level semantic aspects of speech processing were assessed by comparing sentences that were made difficult to understand by the presence of words that were semantically ambiguous compared to matched low-ambiguity sentences. As expected the two severely disabled, but conscious patients showed preserved speech processing at all three levels. However, contrary to the diagnostic criteria defining the vegetative state, three patients (1 traumatic, 2 non-traumatic aetiology) demonstrated some evidence of preserved speech processing. The remaining four patients (1 traumatic, 3 non-traumatic aetiology) with a diagnosis of vegetative state showed no significant activation in response to sound compared with silence. These results provide further evidence that a subset of patients fulfilling the behavioural criteria for the vegetative state retain islands of preserved cognitive function.
PMID: 17827174 [PubMed – indexed for MEDLINE]
3. Neuropsychol Rehabil. 2005 Jul-Sep;15(3-4):307-22. “Assessing level of consciousness and cognitive changes from vegetative state to full recovery.” Bekinschtein T, Tiberti C, Niklison J, Tamashiro M, Ron M, Carpintiero S, Villarreal M, Forcato C, Leiguarda R, Manes F. Institute for Neurological Research (FLENI), Buenos Aires, Argentina.
Although investigations addressing cognitive recovery from the vegetative state have been reported, to date there have been no detailed studies of these patients combining both neuropsychology and functional imaging to monitor and record the recovery of consciousness. This paper describes the recovery of a specific vegetative state (VS) case. The patient (OG) remained in the vegetative state for approximately two months, increasing her level of awareness to a minimally conscious state, where she continued for approximately 70 days. In the course of the ensuing 18 months, she was able to reach an acceptable level of cognitive functioning, with partial levels of independence. Throughout this two year period, she received continuous cognitive evaluation, for which several different tools were applied including coma and low functioning scales, full cognitive batteries, and structural and functional magnetic resonance imaging (MRI).
We present here preliminary data on fMRI using a word presentation paradigm before and after recovery; we also discuss the difficulty of how to determine level of consciousness using the tools currently available, and the subsequent improvement in different cognitive domains. We confirm that accurate diagnosis and proper cognitive assessment are critical for the rehabilitation of patients with disorders of consciousness.
PMID: 16350974 [PubMed – indexed for MEDLINE]
4. Brain Inj. 2004 Sep;18(9):935-40. Further recovery in a potential treatment withdrawal case 10 years after brain injury. McMillan TM, Herbert CM. Psychological Medicine, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK.
A young woman was rendered tetraplegic and anarthric as a result of a traumatic brain injury in 1993. Two years later, she was considered to be in a minimally conscious state and became the subject of legal debate in the UK with regard to withdrawal of artificial feeding and hydration. Before injury, she made a verbal advanced directive that she would not wish to continue living if ever becoming severely disabled. Neuropsychological assessment found statistically significant evidence for sentience and expression of a wish to live and the application to Court was withdrawn. Further meaningful recovery occurred between 7-10 years after injury. She now lives in the community with 24 hour care. She speaks, initiates conversation and actions, expresses clear and consistent preferences and has a spontaneous sense of humour. She uses an electric wheelchair, eats solid food and drinks through a straw. Her mood is variable and sometimes low.
This case demonstrates the need for careful consideration of advanced directives and for specialist neuropsychological assessment in people with severe cognitive and communication difficulties. It supports the view that routine assessment and follow-up of people thought to be in minimally conscious states is important. In addition, it shows that recovery with reduction in disability and significant implications for quality of life can continue for at least 10 years after extremely severe traumatic brain injury. Copyright 2004 Taylor and Francis Ltd
PMID: 15223745 [PubMed – indexed for MEDLINE]
5. Brain Inj. 2003 Jun;17(6):525-33. “Emotional adjustment following cognitive recovery from ‘persistent vegetative state’: psychological and personal perspectives.” Macniven JA, Poz R, Bainbridge K, Gracey F, Wilson BA. University Hospital, Queen’s Medical Centre, Nottingham, UK.
Previously, the cognitive recovery of a 26 year old woman, Kate, who developed a severe encephalomyelopathy and was in a ‘minimally conscious/persistent vegetative state’ for 6 months was reported. After 6 months, Kate began to respond to her environment and, at 2 years post-illness, neuropsychological assessment indicated that Kate was functioning within the normal range on tests of general intellectual functioning, executive functioning and most memory functions (with the exception of visual recognition memory). Although Kate has a severe dysarthria necessitating the use of a communication board and severe physical disabilities that require her to use a wheelchair, she has demonstrated an almost complete cognitive recovery and is among a tiny percentage of minimally conscious patients to do so. This single case report describes the emotional factors central to Kate’s rehabilitation. Using a newly developed model of cognitive rehabilitation as a framework, the pivotal role that emotional and psychological factors played in Kate’s adjustment to the consequences of her illness and the role of psychotherapeutic intervention in facilitating this adjustment are discussed.
PMID: 12745707 [PubMed – indexed for MEDLINE]
6. Clin Rehabil. 2002 Aug;16(5):464-72. “Sensory stimulation of brain-injured individuals in coma or vegetative state: results of a Cochrane systematic review.” Lombardi F, Taricco M, De Tanti A, Telaro E, Liberati A. UO di Riabilitazione Intensiva, Ospedale di Correggio, AUSL Reggio Emilia, Italy.
OBJECTIVES: To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. DESIGN: Systematic review of randomized control trials (RCT) and nonrandomized controlled clinical trials (CCT) comparing any type of stimulation programmes with standard rehabilitation in patients in coma or vegetative state. The Injuries Group specialized register, the Cochrane Controlled trial register, EMBASE, MEDLINE, CINAHL, PSYCHLIT from 1966 to January 2002 were searched without language restriction. Reference lists of articles were scanned and experts in the area contacted to find other relevant studies.
Abstracts and papers found were initially screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality, resolving disagreement by consensus. OUTCOME MEASURES: Duration of unconsciousness (including coma and vegetative state) defined as the time between trauma and objective recovery of the ability to respond to verbal commands; level of consciousness, as measured by the Glasgow Coma Scale (GCS); level of cognitive functioning (LCF); functional outcomes, as measured by Glasgow Outcome Scale (GOS) or by Disability Rating Scale; negative effects (e.g. increased intracranial pressure). RESULTS: Three studies (one RCT and two CCTs) with
68 traumatic brain-injured patients in total, most of whom were road accident victims, met the inclusion criteria. The overall methodological quality was poor and studies differed widely in terms of study design and conduct. Moreover, due to the diversity in reporting of outcome measures, a quantitative metanalysis was not possible. None of the three studies provided useful and valid results on outcomes of clinical relevance for coma patients. CONCLUSIONS: This systematic review indicates that there is no reliable evidence to support the effectiveness of multisensory stimulation programmes in patients in coma or the vegetative state.
PMID: 12194617 [PubMed – indexed for MEDLINE]
7. NeuroRehabilitation. 2002;17(3):231-6. “Vegetative state and minimally responsive patients–regional survey, long-term case outcomes and service recommendations.” Wilson FC, Harpur J, Watson T, Morrow JI. Down Lisburn H&SS Trust, Thompson House Hospital, Lisburn, Northern Ireland, UK.
A regional survey of Consultant level Neurology, Neurosurgical and Rehabilitation staff identified a retrospective estimate of patients in vegetative or minimally responsive states from their own clinical caseloads (October 1995–97). 35 patients were identified; the majority of whom were not currently placed in specialist brain injury facilities following acute hospital intervention.
In addition, a retrospective review of referrals to this unit (1995–2001) was also undertaken. Of twelve patients referred as being in a vegetative or minimally responsive state, 4 were considered as having been misdiagnosed (emerged) at follow-up; 2 had been presumed to be vegetative for at least one year. All patients remained severely physically disabled (i.e., totally dependent for care) but four were nevertheless able to communicate their preference in quality of life issues, care decisions etc. either by verbal or non-verbal means.
Vegetative-minimally responsive patients or those who are very severely and multiply disabled need skilled and frequently prolonged assessment. Appropriate management requires an experienced inter-disciplinary as opposed to multidisciplinary team working style, whose skill repertoire equips them to recognise often-subtle improvements in cognitive function and act to maximise individual patient’s quality of life. The current paucity of service provision for this vulnerable group of patients is highlighted.
PMID: 12237504 [PubMed – indexed for MEDLINE]
8. Brain Inj. 2001 Dec;15(12):1083-92. “Cognitive recovery from ‘persistent vegetative state’: psychological and personal perspectives.” Wilson BA, Gracey F, Bainbridge K. MRC Cognition and Brain Sciences Unit, Box 58, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK.
This study reports on the case of a young woman who, at the age of 26, developed a severe encephalomyelopathy and was in a vegetative state or minimally conscious state for 6 months. She showed a sleep-wake cycle, but no evidence of cognitive functioning. Six months after her illness, she began to respond to her environment and eventually returned home to the care of her parents, with regular periods of respite care in a home for people with severe physical disabilities. She remains in a wheelchair with a severe dysarthria and communicates via a letter board. Two years after her illness, staff at the home requested an assessment of her cognitive functioning. On the WAIS-R verbal scale and the Raven’s Progressive Matrices, the woman’s scores were in the normal range.
So too were her recognition of real versus nonsense words and her memory functioning (apart from a visual recognition memory test which was in the impaired range). Although she enjoyed the tests, she became distressed when asked about her illness and previous hospitalization. She was reassessed 1 year later, when there were few significant changes in her test scores but she could talk about her illness and hospitalization without becoming distressed. She was angry, however, about her experiences in the first hospital. Further tests suggested good executive functioning. In short, this woman’s cognitive functioning is in the normal range for most tasks assessed, despite a severe physical disability and dysarthria, and despite the fact that she was vegetative for 6 months.
Although some recovery following 6 months of being vegetative/minimally conscious is not unknown, it is rare, particularly for those with non-traumatic injuries, and the majority of people similarly affected remain with significant cognitive deficits. This client has, by and large, made an almost complete cognitive recovery.
She feels positive about her life now and says the formal assessment showed people she was not stupid and this made her happy. The paper concludes with the young woman’s own comments and views about what happened to her and her present feelings.
PMID: 11712954 [PubMed – indexed for MEDLINE]
9. Lancet. 2000 May 20;355(9217):1790-1. “Restoration of thalamocortical connectivity after recovery from persistent vegetative state.” Laureys S, Faymonville ME, Luxen A, Lamy M, Franck G, Maquet P. Erratum in:
Lancet 2000 May 27;355(9218):1916.
By use of H2(15)O positron emission tomography we have shown that functional connectivity between intralaminar thalamic nuclei and prefrontal and anterior cingulate cortices was altered during vegetative state but not after recovery of consciousness.
PMID: 10832834 [PubMed – indexed for MEDLINE]
10. J Insur Med. 1998;30(2):113-4. “Use of MRI in prediction of recovery from persistent vegetative state.” Goodwin L. Transamerica Reinsurance, Charlotte, NC 28202, USA.
PMID: 10339293 [PubMed – indexed for MEDLINE]
11. BMJ. 1993 Jun 12;306(6892):1597-600. “Recovery of patients after four months or more in the persistent vegetative state.” Andrews K. Royal Hospital and Home, Putney, London.
Comment in: BMJ. 1993 Jun 12;306(6892):1602-3.
A retrospective review was made of the case notes of 43 consecutive patients admitted to a unit specialising in the rehabilitation of people in the persistent vegetative state. Eleven of these patients regained awareness four months or more after suffering brain damage. The time to the first reported incidence of eye tracking was between four months and three years, and the time to the first response to command was between four and 12 months. Only one patient was eventually unable to communicate, six could use non-verbal methods of indicating at least a yes or no response, and four were able to speak. Six patients remained totally dependent while two became independent in daily activities. Four patients became independent in feeding, three required help, and four remained on gastrostomy feeding. Thus some patients can regain awareness after more than four months in a vegetative state, and, although few reach full independence, most can achieve an improved quality of life within the limitations of their disabilities.
The recovery period is prolonged and may continue for several years. Even patients with profound brain damage should be offered the opportunity of a specialist rehabilitation programme.
PMCID: PMC1678008
PMID: 8329926 [PubMed – indexed for MEDLINE]
12. Clin Electroencephalogr. 1991 Jul;22(3):141-3. “Recovery of cognition from persistent vegetative state in a child with normal somatosensory evoked potentials.” Tsao CY, Ellingson RJ, Wright FS. Department of Pediatrics, Children’s Hospital, Ohio State University, Columbus 43205.
The absence of bilateral early cortical SEPs in a PVS due to nontraumatic coma is usually associated with failure to recover cognition or awareness, although rarely patients with bilaterally absent cortical SEPs in posttraumatic PVS may regain cognition. On the other hand, normal cortical SEPs in nontraumatic coma may be related to favorable outcomes as shown in this patient and other reports.
Our patient is unique in that he had had serial normal SEPs, was in a PVS for 7 1/2 months, and recovered cognition, but not without cost in terms of damage to intellectual capability. Further long-term clinical follow-up studies to correlate clinical outcome with serial SEP data may be indicated.
PMID: 1879052 [PubMed – indexed for MEDLINE]
13. Intensive Care Med. 1991;17(3):149-53. “HM-PAO-SPECT in persistent vegetative state after head injury: prognostic indicator of the likelihood of recovery?” Oder W, Goldenberg G, Podreka I, Deecke L. Neurological Clinic, University of Vienna, Austria.
Management of patients presenting with traumatic persistent vegetative state (PVS) calls for extensive resources. The ability to predict whether or not a patient is likely to recover is a critical issue. In 12 patients with PVS admitted consecutively for early rehabilitation after head injury, pattern of brain activity was measured by 99mTc-hexamethyl-propylenamineoxime (99mTc-HM-PAO) brain SPECT (single photon emission computer tomography). All patients were re-investigated after a mean observation period of 3 years. A global reduction of cortical blood flow was a reliable predictor of poor long-term outcome, but the demonstration of only focal deficits did not reliably indicate a favourable outcome. Brain SPECT may help to improve outcome prediction in patients with traumatic PVS.
PMID: 2071761 [PubMed – indexed for MEDLINE]
14. Brain Inj. 1990 Oct-Dec;4(4):315-27. “Deep-brain stimulation in a persistent vegetative state: follow-up results and criteria for selection of candidates.” Tsubokawa T, Yamamoto T, Katayama Y, Hirayama T, Maejima S, Moriya T. Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan.
Eight cases of a persistent vegetative state caused by brain damage were treated by chronic deep-brain stimulation (stimulation target: the mesencephalic reticular formation and/or non-specific thalamic nucleus) over a period of more than 6 months. Three of the patients are currently able to communicate and to express their demands by voice and one other patient has recovered very close to this state. These four cases showed changeable spectrograms with desynchronization on continuous EEG recording and all components of the BSR and SER could be recorded except for prolonged latency of both N20 (SER) and the V wave (BSR) 2 months after the initial coma. Following chronic deep-brain stimulation, EEG and behavioural arousal responses were observed with increased r-CBF, r-CMRO2 and r-CMRGL in the whole brain tissue. After 3-6 months of chronic deep brain stimulation, the prolonged coma scale rose in four of the eight cases and three cases emerged from the persistent vegetative state. Transmitter substances and their metabolites were also found to be increased in the CSF after chronic deep-brain stimulation. Based on these findings, chronic deep-brain stimulation represents a useful kind of treatment that can lead to emergence from a persistent vegetative state, if the candidate is selected by electrophysiological studies 2 months after the initial insult and if the stimulation is applied for more than 6-8 months using a high-safety chronic deep-brain stimulating instrument.
PMID: 2252964 [PubMed – indexed for MEDLINE]
15. Hastings Cent Rep. 1989 Jul-Aug;19(4):14-5. “Recovery from persistent vegetative state? The case of Carrie Coons.” Steinbock B. State University of New York, Albany.
PMID: 2501234 [PubMed – indexed for MEDLINE]
