John Cornwell
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Kate Bainbridge is a lively 37-year-old former schoolteacher. We are communicating in the conservatory of her parents’ home in south Cambridge. She has expressive eyes and a broad and ready smile, but she can utter only occasional single words with difficulty. She sits in a wheelchair “speaking” with the aid of a letter-board, using her left forefinger to spell out words individually.
Ten years ago, Kate went into a deep coma and was on a ventilator for several weeks. She had suffered severe brain inflammation after contracting a viral infection. When she came out of the coma, she opened her eyes and could breathe naturally, but she was unresponsive to speech and visual stimuli, and appeared to lack all conscious awareness. She was still in this condition four months after falling ill, and was later diagnosed to be in a persistent vegetative state, or PVS: in other words, persistently unaware. But the diagnosis was wrong.
Although Kate could not speak, or hear properly, or make any kind of signal, or take in sustenance except through a tube into the stomach, she was sometimes aware of herself and her surroundings. She had a raging thirst that was not alleviated by the ward staff. She was racked with pain. Sometimes she’d cry out, but the ward staff thought it was just a reflex action. Kate suffered so much pain and despair that she tried to take her own life by holding her breath.
Then a Cambridge neuroscientist called Dr Adrian Owen put her in a special kind of scanner and performed an unprecedented experiment. It revealed evidence of fluctuating levels of brain activation when she was presented with pictures of her parents. From that point, she started her long journey back into the world. This is a story about brain-impaired patients who come gradually out of coma into “minimal awareness” after being misdiagnosed as being in PVS: breathing, appearing to be wakeful, yet deemed to be dead to themselves and the world. It is also about the disastrous consequences of such misdiagnoses, estimated in the UK and other countries to be running at two in five cases. And, crucially, it is about a neuroscientific research programme that is set to transform the prospects of diagnosis, treatment and rehabilitation of brain-injured people the world over.
Only an estimated 20% of patients return, like the Top Gear presenter Richard Hammond after his car crash in September, to fully functioning normality after serious brain injury. The range of disability following brain damage is hugely varied in type and severity. It is not known how many PVS and minimally conscious patients there are in this country, since no central registry exists. It is likely, according to a canvass of many neurology professionals, to be in the tens of thousands. More certain is the grim reality of hospital wards and long-term care homes where the persistently vegetative and the minimally conscious languish, sometimes for decades.
To write this article I have had the sobering experience of witnessing the plight of patients with severely impaired consciousness – the intubations, the double incontinence, the stricken semicircle of wheelchairs parked before the unwatched day-room TV. And I have met the anguished families of those who are denied final grieving and closure for a loved one condemned to what appears a living death. All too often I have spoken to a wife or husband, or mother or father, who will travel anything up to two hours each way by taxi, every day, to spend time with an unresponsive child or spouse.
But here’s at least one mordantly amusing and true story told to me by a psychologist at Putney’s Royal Hospital for Neuro-disability. “Young man with motorbike head injury in a coma. His mum, a keen evangelical, comes every day with friends to sing Onward, Christian Soldiers by his bedside. She’s hoping to stimulate his brain into action. It works: he comes round, but he can’t speak. So they fit him up with one of those Stephen Hawking-type laptops, and the first words he speaks are: “For God’s sake, Mum, shut it!” That’s about as funny as it gets on a brain-injury ward, but there’s a serious take-home message. Even minimally aware patients can retain emotions, personality, a capacity to suffer – and, as the young biker showed, attitude.
The biggest, most tragic clinical myth about brain injury today is that PVS can be reliably diagnosed by bedside observation alone. It has in fact been known for at least a decade, ever since a key survey of brain-injured patients, that misdiagnosis of the condition runs at more than 40%, a statistic originally calculated by Professor Keith Andrews, former head of the Putney hospital, and confirmed by recent surveys in Europe and North America. This means that valuable rehabilitation strategies are routinely neglected, and misdiagnosed patients end up on unsuitable wards or in care homes where their needs are neither understood nor met.
Up to 12,000 people under 40 in this country suffer traumatic brain injury every year, and there are serious deficiencies in their rehabilitation, according to Professor John Pickard, head of neurosurgery at Addenbrooke’s hospital, Cambridge: “The tendency for patients to be left to languish on general medical, surgical and orthopaedic wards continues to their detriment.” The shocking term being used by campaigning neurologists and neurosurgeons is that unknown numbers of patients are being just “warehoused”.
Christine Simpson, a mother of two in her mid-fifties, and her husband, Colin, encountered the PVS misdiagnosis phenomenon two years ago. After suffering a brainstem stroke, Christine was first admitted to the intensive-care unit at the Princess Alexandra hospital, Harlow, then transferred to a general respiratory ward, where she remained for about a month.
“I was told that she would probably get a chest infection and not survive more than a few weeks,” says Colin. “Even on the respiratory ward I was told she was still in coma, though she was communicating with me at times through her eye movements. Only because myself and our two grown-up sons were constantly at her bedside did she get proper attention.
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An older brother was in a coma for six months. A close lady friend of his went there often or everyday to play music tapes by his bedside. Apparently, this is what woke him up out of his coma, after about a month or so.
Brown, Queensland,
Why do people have to say "murdered" because they have an opinion that disagrees with ending medical help for people in PVS? If you cause a car crash and your passenger dies, have you murdered them? No. Get over yourselves and just be grateful you havn't got to make such a tough decision yourself.
Neil, Birmingham, U.K
Artificially alive? What does that even mean? These people are living human beings. Why should they be murdered?
Mo, Chicago, USA
Technology is advancing far ahead of our wisdom. Anybody can now be kept artifically 'alive' for decades on end.
People should not be kept artifically alive unless they have signed a form allowing for such medical experimentation.
I dread that I could be condemned to such a hellish existence.
Emily, Galway, Ireland
One realizes how much a part semantics play in the PVS of the press by the sentence, "Terri was finally allowed to die in March 2005." Terri didn't request her death, so, obviously, Terri was not "allowed" to die. She was starved to death by her husband, his attorney and judges.
Renata, Washington, DC, USA
In my experience not all communication is based on the 5 senses. Years ago, as a student nurse, I looked after people who were in comas. 2 of them stand out in my memory because I was sure they were aware. From one I could feel waves of deep, deep sadness. From the other I could feel anger. I don't know if other nurses could feel this as it was never discussed however we were taught to always treat unconscious people as conscious because hearing is the last sense to go and the first to return.
Jane, Birmingham,
".. in the case of 'Mrs K' it might just be a lot more convenient for her family if it was assumed she was in a PVS - and withdrawing feeding so the family can get on with their lives? Never mind Mrs K's life... " What life, exactly? Life support technology is for use in temporary critical care.
Isadora, London,
Personally, I'd rather get "murdered", and have what's left of me save three or four other lives in the form of organ donation, than linger in some nightmare frozen state with a 10-20% chance of recovery, and do nothing but consume resources, money, and my loved one's time and energy.
Evan B., San Jose, CA, United States
As long as I could communicate (through assistive technologies) and feel like I could make a contribution, I'd opt for a life in a "disabled" state than no life at all. A concious state where no one knows that you are aware, however, is a cruel fate that people should not, but apparently do suffer.
Alvin, San Diego, CA, USA
Thank you John Cornwell for bringing this serious issue to public awareness. Hopefully it doe not end here and someone would be motivated to correct this horrible dilemma.
Michael, Placerville, California
I had a sister who went into a coma 2 times. Once after an auto accident. The other time (20 years later) after a suicide attempt . On both occasions, a she was diagnosed as having 0% chance of recovery. They wanted us to sign forms for organ removal. She fully recovered both times.
Dave, Boston, USA
I'm 62 years old and don't want to live for months or years with minimal awareness only to "recover" enough for my relatives to care for me the rest of the my life. I'll put in my living will that a diagnosis of PVS means, "pull the tube," I don't want to go there.
Suzy S, Scottsdale, AZ
I was in a coma for a week in France in 1967 after my appendix ruptured. I can remember slowly coming back to full consciousness. I could hear people talking in the room days before I could see them or move.
Roon, Montreal,
Interesting - how many people have been murdered by their relatives and the medical profession because they were diagnosed as PVS?
SallyR., London, UK
Oh, so in the case of 'Mrs K' it might just be a lot more convenient for her family if it was assumed she was in a PVS - without checking if this was really the case - and withdrawing feeding so the family can get on with their lives? Never mind Mrs K's life...
Chris, St Leonards, UK
Please could you let me know if there are medical test going on for people who suffer from Locked in Syndrome? I would be greatfull if you could let me know . Hoping you can help me in this matter as my husband is one who suffers from this.
Theresa Taylor, Billericay Essex, England