by Jan Baughman
(Swans - January 13, 2014) There are many steps on the continuum from consciousness to death, ranging from coma -- which can be reversible -- to vegetative state, persistent (over 4 weeks) or permanent (over 1 year), in which serious brain damage exists but the body remains in physiological arousal, i.e., responds to stimuli, yet recovery is highly unlikely and life support measures are needed. The unresponsive state of coma can be caused by many factors, from drug or alcohol overdose, hypoglycemia, to bleeding from head trauma. A coma can also be medically-induced to allow a patient's brain to recover from trauma. Legendary Formula One driver Michael Schumacher has been in an induced coma since December 29 after suffering severe head trauma in a skiing accident, which caused bleeding in his brain necessitating two surgeries to relieve the pressure. The extent of damage and his prognosis for recovery are either unknown or not being revealed, and his family, friends, and fans anxiously await his recovery. Meanwhile, after eight years in a coma following a severe stroke and with little chance of recovery, Israel's former prime minister Ariel Sharon died at the age of 85.
Terri Schiavo's persistent vegetative state dragged on for 15 years while her husband and parents and just about every US politician argued over her husband's wishes to remove her feeding tube. He had taken her to various hospitals for all kinds of therapy over 3 years to try to rehabilitate her, to no avail. The tube was removed and reinserted at the order of one court or another. He ultimately prevailed, and Schiavo, having become a political pawn, died within two weeks.
More recently, on December 9, 2013, a 13-year-old Oakland, California girl, Jahi McMath, suffered complications including uncontrollable bleeding following a tonsillectomy. Doctors declared her brain dead, to have "irreversible cessation of circulatory and respiratory functions." Her death was confirmed by independent doctors, certified by the coroner, but her family, believing she's still alive, went to court to keep her on a ventilator and began a search for a long-term care facility that would take her. They hospital refused to insert breathing and feeding tubes, and she was ultimately transferred to an undisclosed location, where medical ethicist Laurence McCullough says her body will "start to break down and decay" while her lungs continue to be pumped full of air.
The reverse happened in November to a Texas woman, Marlise Munoz, who suffered a pulmonary embolism -- a blood clot in the lung -- and was also declared brain dead. Her husband, a paramedic like his wife, insisted that she would not want to be kept on life support and her parents concurred. It happened that at the time of her collapse she was 14 weeks pregnant, and a Texas law requires that one cannot withdraw life support from a pregnant woman, no matter her wishes, how far along the pregnancy is, or the health status of the fetus, which is being kept alive in a dead body.
There are numerous tests to evaluate brain function, from response to pain stimuli, presence of eye and motor movement, to elegant neuroimaging techniques that assess brain metabolism, but we still have much to learn about what is happening in the brain at various stages of life and death. Until we can better characterize how and if a patient's brain is functioning while trapped in a seemingly lifeless body, what happens to us as that patient will remain subject to political whims, local laws, and our family's values, and not necessarily our own end-of-life wishes -- something each of us should contemplate and communicate in an advance health care directive before our ability to do so ceases and we are subject to a quality of life we would never want and can never imagine.
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