A vegetative state, or unaware and unresponsive state, is a specific neurological diagnosis in which a person has a functioning brain stem but no consciousness or cognitive function. Descriptive Title. This may be done when the gastrointestinal tract is not intact or does not function. 6See William E. May, Robert Barry, Orville Griese, Germain Grisez, Brian Johnstone, Thomas J. Marzen, Bishop James T. McHugh, Gilbert Meilaender, Mark Siegler, William B. Smith, Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons, in "Issues in Law & Medicine" 3 (Winter, 1987) 203-217. The "persistent vegetative state" is a form of deep unconsciousness. The damage left him blind, incontinent and unable to move or communicate. News, analysis & spirituality by email, twice-weekly from CatholicCulture.org. If they should fall sick or be otherwise in danger of death, they surely have a right to "ordinary" care, and others have a serious moral responsibility to protect and preserve their lives unless the efforts to do so are futile or excessively burdensome. "I have to do his feeds and then, last thing at night, see he's alright, move him about and put cushions all around him to stop him getting bedsores. A stricter obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. "Extraordinary" means would seem to be those means which are optional because they are ineffective or a grave burden in helping a person strive for the spiritual purpose of life.13. Iain is thought to be the longest surviving vegetative state patient in the UK, an unenviable record. Between these two extremes, patients may be said to be in a vegetative state or exhibit unresponsive wakefulness, characterized by open eyes and basic reflexes, but no signs of awareness. She had been in a persistent vegetative state since then, and was maintained on tube feedings. I will return to this problem below, in commenting on views which I deem unacceptable and indeed dangerous. This interpretation, or in my judgment, misinterpretation of the teaching of Pius XII has been advanced in particular by Kevin O'Rourke, OP, in several very influential essays dealing with the care of permanently unconscious persons.11 A view very similar to O'Rourke's, although different in some respects, has been set forth by James Walter and Thomas V. Shannon.12 Here I will simply recount O'Rourke's position insofar as on the matters to be taken up Walter and Shannon are in agreement with him. Criteria for withholding/withdrawing treatment, My purpose here is to articulate the criteria necessary for distinguishing between treatments which the Catholic tradition has called "ordinary" or, more recently, "proportionate," and those termed "extraordinary" or, more recently, "disproportionate.". The family only learned they could apply to the courts years afterwards when an expert was brought in to assess Christopher's accident compensation claim. The nurses caring for her used the time when they would have been preparing statements in this case to provide care. Patients in a vegetative state do not respond to what is happening around them and exhibit no signs of conscious awareness. At that point the outcome for her was unclear." As a young, proud, super-fit marine, it is a life he never would have wanted. It is difficult to find precise figures for the numbers affected, but experts believe there could be as many as 5,000 people in the UK enduring what has been described as a "living death". : Rahway, N.J.: Merck Sharp and Dohme Research Laboratories, 1987), pp. (5) Pennsylvania Conference of Catholic Bishops, Nutrition and Hydration: Moral Considerations (January 14, 1992) in "Origins: NC News Service" 21 (January 30, 1992) 542-553. This document came to a conclusion opposite to that reached by the Pennsylvania Bishops and the U.S. Bishops Pro-Life Committee. A more adequate and complete explanation of "ordinary" means to prolong life would be: those means which are obligatory because they enable a person to strive for the spiritual purpose of life. This lack of reasonable hope or benefit renders the artificially invasive medical treatments futile and thus extraordinary, disproportionate and unduly burdensome," and consequently it would be morally permissible to stop providing food by these artificial means (547). The upper part of the brain, the cerebrum, gives evidence of impaired or failed operation. Since 1992, following the landmark case of Hillsborough victim Tony Bland, it has been possible for an application to be made to the Court of Protection for permission to end a vegetative state patient's life by withdrawing food and hydration. Professor Turner-Stokes hopes the team's work will ultimately help improve the process which the David family and others believe has let them down. Previously, the term persistent vegetative state (PVS) was used to describe all patients with prolonged disorders of consciousness. Here Pius indicates that "ordinary" medical treatment is that kind of treatment which offers some reasonable hope of benefiting the subject without imposing unacceptable burdens upon him or others, whereas "extraordinary" treatment is the kind that imposes unacceptable burdens on the subject and/or others. The Pennsylvania Bishops inform their readers that they have here summarized information on tubal feeding set forth in standard medical texts such as The Merck Manual of Diagnosis and Therapy, Robert Berkow, M.D., ed. This can be accomplished by means of a nasogastric (through the nose and into the stomach) or nasoduodenal (through the nose and into the upper end of the small bowel) tube or it can also be done through a gastronomy (an opening directly into the stomach) or jejunostomy (an opening into the upper part of the small bowel). Also see the separate article Coma. Some people will wake up after a few weeks, while others may go into a vegetative or minimally conscious state (see recovering from a coma). This week, two articles discuss the problems encountered by relatives and professionals caring for people in the persistent vegetative state (pp 352 and 372). Since persons diagnosed as being in the "persisent vegetative state" are by no means imminently in danger of death and since their lives can be prolonged, perhaps for many years, if they are fed and nourished, the principal moral question raised in caring for them is whether or not it is morally obligatory to provide them with "food" by the artificial means described in footnote no. For the present I can simply say that this document clearly indicates that medical treatments judged, on objective grounds, to impose grave burdens either upon the subject being treated or his family or, indeed, the human community of which the subject is a member, are not morally required and hence can be legitimately withheld or withdrawn. 8Congregation for the Doctrine of the Faith, Declaration on Euthanasia, sect. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health so long as he does not fail in some more important duty.7. 1. And because of advances in medical science meaning that more people survive what would previously have been fatal injuries, the figures are set to continue to grow. First of all, such persons, even including those in the "persistent vegetative state," can be fed orally provided that the swallowing reflex is sufficiently unimpaired. Erroneous criteria for judging means "extraordinary" or "disproportionate", In the previous section I called attention to Pope Pius XII's address to anesthesiologists not only because it is an important magisterial document relevant to identifying criteria necessary for distinguishing between "ordinary" (=morally obligatory) and "extraordinary" (=morally elective) means of treatment but also because one interpretation of a singularly important passage from this document has been used by several theologians to justify withholding or withdrawing artificially provided food from persons in the "persistent vegetative state.". I think it could help streamline things.". The Bishops describe enteral and parenteral methods as follows: "Enteral (within the bowel) feeding means that the nourishment is placed directly into the upper end of the small intestine. (4) Texas Conference of Catholic Bishops, On Withdrawing Artificial Nutrition and Hydration (May 7, 1990) in "Origins: NC News Service" 20 (1990) 53-55. "At the current time there is not a great deal of clarity about what the process should be, for example there isn't a clear protocol for what should have been done prior to approaching the court," she said. "I think it's very traumatic for the families, it's quite a long, drawn-out process. Caring for Patients in a Persistent Vegetative State. 6. In contrast, a coma is a state that lacks both awareness and wakefulness. © 2020 BBC. Caring for Persons in the . However, their condition has stabilized and they are not in any immediate danger of death so long as they are given appropriate "food," which can be provided to them "artificially" by means of tubes.4. I will then (2) apply these criteria to the artificial feeding of patients in the "persistent vegetative state," developing and clarifying considerations set forth in the 1987 article. "If he's got a chest infection or anything wrong, I've got a baby alarm and I can hear him.". This is a good example of an unanswerable question, because: 1. A former nurse, the diminutive 83-year-old wakes at 7.30am every day to begin a care regime which would challenge someone half her age. "For some clinicians [the withdrawal of nutrition to allow a patient to die] is not morally acceptable. 12See James Walter, Food and Water: An Ethical Burden in "Commonweal" (November 21, 1986) 616-619; James Walter and Thomas A. Shannon, The PVS Patient and the Foregoing/Withdrawing of Medical Nutrition and Hydration in "Theological Studies" 49 (1988) 623-647. Benefits programs pay families to care for seniors. While caring for a person in a vegetative or minimally conscious state is an enormous challenge, use of appropriate resources, as described above, can be a big help. This is done under sedation to ensure the patient feels no pain or distress. There are situations in which this is not the case, but those are the exceptions and should not be made into the rule" (550). The recovery is usually considered impossible, especially after it has progressed to the condition known as permanent vegetative state. O'Rourke correctly interprets the teaching of Pius XII when he says that a means is extraordinary if it imposes a grave burden on a person and prevents him from pursuing the spiritual goal of life. Such means are surely "ordinary" or "proportionate." Cipolletta S(1), Gius E, Bastianelli A. I will conclude (3) by considering conditions that could justify putting limits to the care morally due to persons in this state. A true coma, which is never permanent, is a state of "unarousable unresponsiveness" which may last as long as six months but will eventually resolve itself into another state.2 The person may emerge into consciousness (of varying degrees) or sink into the "persistent vegetative state," and it may take a long time, even months, to make a correct diagnosis of the patient's true condition. In this section you can find out about the experience of having a relative in a vegetative or minimally conscious state. A vegetative state is when someone is awake but is showing no signs of awareness. Use of this expression leads some to think that individuals in this state are no longer truly human persons but rather "vegetables," but this, of course, is not true at all. Patients in a vegetative state are awake, breathe on their own, and seem to go in and out of sleep. Mr David's family believe he felt his wife had suffered enough. He is fed through a tube in his chest. It stated that no matter what terms are used to signify the distinction, it would nonetheless be possible to make a correct judgment, by studying the type of treatment to be used, its degrees of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.8, Moreover, the same document maintained that "one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Can someone in a vegetative state dream? It is likewise legitimate to take into account the burdens, including financial burdens, which the treatment will impose upon others. Once someone has received a permanent vegetative state diagnosis, the chance of waking up is extremely unlikely, but still possible. 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Statements on the matter representative of individual bishops are those of (1) The Most Reverend Louis Gelineau Bishop of Providence, R.I., and (2) The Most Reverend James McHugh, Bishop of Camden, N.J. Bishop Gelineau issued a statement, On Removing Nutrition and Water from Comatose Woman (January 10, 1988; printed in "Origins: NC News Service" 17 (January 21, 1988) 546-547) in which he declared that "the medical treatments which are being provided the patient, even those which are supplying nutrition and hydration artificially, offer no reasonable hope of benefit to her. It is to be noted that 2 of the 18 bishop members of the Texas Conference refused to sign the document. Other U.S. Bishops and conferences (e.g., the Conferences of Washington, Florida, and Bishop John Myer of Peoria) have likewise issued documents on this question, but those noted here are representative. 'No corners cut' in vaccine approval, regulator says, 'One boy stood out to me - he's now my son', 'I wake up wondering if I still have a job', Why it feels like a government without a majority, 'We've lost a day of trade' over lockdown end date. In addition, many people have had to leave their jobs or cut back on hours in … Professor Derick Wade, consultant in neurological rehabilitation, believes it is crucial to inform families of this and all of the options open to them at every stage. The lives of the Pistorius family centered around caring for Martin. Unfortunately, her whole family has been torn apart by the co… On recovery from the coma state, VS/UWS is characterised by the return of arousal without signs of awareness. 13O'Rourke, Evolution of Church Teaching on the Prolongation of Life, 32. Most patients in a prolonged vegetative or minimally conscious state will eventually be transferred from hospital to a rehabilitation or long-term care setting. Yet, on O'Rourke's analysis, they would be "extraordinary" inasmuch as they would in no way be effective in helping this person to pursue the spiritual purpose of life. These bishops judged that forgoing or withdrawing of artificial nutrition and hydration from a permanently unconscious person, whom they judged "stricken with a lethal pathology which, without artificial nutrition and hydration, will lead to death," is "simply accepting the fact that the person has come to the end of his or her pilgrimage and should not be impeded [by continuing the artificial feeding] from taking the final step" (54). "Then I have a last look at him at quarter to one in the morning, and if he's sleeping, I'm fine then and I go to sleep myself. Complete Honest Opinion from Caregivers of Vegetative State/Minimally Conscious Survivors After having made the decision to keep your loved one alive and hope for the best, was it the right decision? CARING FOR PERSONS IN THE “PERSISTENT VEGETATIVE STATE” AND POPE JOHN PAUL II’S MARCH 20 2004 ADDRESS “ON LIFE-SUSTAINING TREATMENTS AND THE VEGETATIVE STATE” * William E. May. Caring for an older adult is expensive. Without Advance Directives, treatment decisions for patients with Persistent Vegetative State are left to healthcare professionals and families. A major document of the Magisterium relevant to our question is the Declaration on Euthanasia issued by the Congregation for the Doctrine of the Faith in 1980. This is just one of a number of heartbreaking dilemmas faced by the families of those left in a vegetative state. Such individuals are still human persons whose lives are inviolable. File on 4 is on BBC Radio 4 on Tuesday 21 June at 2000 BST and Sunday 26 June at 1700 BST. IV. Hypothalamic and medullary brain stem functions remain intact to support cardiorespiratory and autonomic functions and are sufficient for survival if medical and nursing care is adequate. "I think about it all the time. The Pennsylvania Bishops, whose document is by far the most extensive and carefully prepared and annotated, declare at the end of their study: "As a general conclusion, in almost every instance there is an obligation to continue supplying nutrition and hydration to the unconscious patient. The Pope himself did not address the specific criteria for distinguishing between treatments which are ordinary or proportionate and those which are extraordinary or disproportionate. In setting forth these criteria I will also criticize criteria proposed by influential Catholic theologians because of their inadequacies. Statement on Tube Feeding: An Ethical Analysis, "America" 155 (November 22, 1986) 321-323, 331 (an essay reprinted by the Society for the Right to Die, an advocacy group for legalizing euthanasia, in its newsletter); Different Viewpoints: Should Nutrition and Hydration Be Provided to Permanently Unconscious and Other Mentally Disabled Persons? We heard about the disagreements between her family and her husband as to what Terri would want in this situation. Culture of Life Foundation 1350 Connecticut Avenue NW Suite 1210 Washington, D.C. 20036 Voice: 202-331-9800 Fax: 202-331-9540 E-mail: [email protected], This item 3481 digitally provided courtesy of CatholicCulture.org. 3See Ronald Cranford, The Persistent Vegetative State: The Medical Reality (Getting the Facts Straight), in "Hastings Center Report" 18 (February-March, 1988) 27-32. The new ‘Nigerian princes’ of hacking? Rather, he outlined a general approach that seems clear enough, but one which obviously needs interpretation and requires further specification. Mother seeks to let brain-damaged daughter die, The new ‘Nigerian princes’ of hacking? Professor Lynn Turner-Stokes is chair of the Royal College of Physicians working party which has been set up to review the issues around the diagnosis and care of vegetative patients. NPR reported that Rodney Pistorius would wake up at 5 a.m. every day to get his son dressed and take him to a special care center. A vegetative state differs both from a coma and brain death. A vegetative state is when a person is awake but showing no signs of awareness. There are out-of-pocket costs for medical supplies, prescription drug co-pays, home modifications, home care help, and more.. Patients usually progress from a coma to either a minimally conscious or vegetative state, and these states can last a few weeks, months or years. 1It is in my opinion unfortunate that the expression "persistent vegetative state" has been employed to describe the condition of human persons. A few families also try home care (see ‘Caring … "1 From the perspective of medicine, individuals in this condition are not comatose. 11See the following: Kevin O'Rourke, OP, Evolution of Church Teaching on the Prolongation of Life, in "Health Progress" 69 (January-February 1988) 28-35; The A.M.A. Respite care, financial support, the sympathetic cooperation of medical pro- The rest of us must not abandon these families, but reach out to give them every possible assis-tance so they will not face their burdens alone. The former Royal Marine, who also served in the Foreign Legion, suffered severe brain injuries after being knocked over by a car in 1989. Here you can hear and see people share their personal stories. But he errs greatly, I hold, when he claims that a means is extraordinary when it is "ineffective...in helping a person strive for the spiritual purpose of life" and that a means is ordinary precisely because it enables a person to strive for the spiritual purpose of life. A central problem in interpreting this statement of Pope Pius XII, as will be seen, has to do with the proper way of understanding what he meant when he said that life, i.e., bodily, physical life, is subordinated to "spiritual ends." Withdrawal of feeding tubes raises ethical questions, as level of consciousness is difficult to diagnose (Wade, 2001, p. 352). "He'll lie there and suffer, unable to moan or groan or call for help and they won't notice. 7Pope Pius XII, The Prolongation of Life: Allocution to the International Congress of Anesthesiologists (November 24, 1957), in "The Pope Speaks" 4 (1958) 396. They cannot do so because in order to do so a person must be able to make judgments and free choices. (15th ed. As with vegetative state, a continuing minimally conscious state means it's lasted longer than 4 weeks. This happened to 53-year-old Helen Watson from Leicestershire, whose sixteen-year-old son Christopher was severely injured in a road accident on his way back to boarding school in 2006. O'Rourke's position is in large measure rooted in his understanding of the passage from Pope Pius XII's address that we have already examined, in particular, that portion of his talk in which Pius said that excessively burdensome treatments would "render the attainment of the higher, more important good too difficult" and that "life, health, all temporal activities are in fact subordinated to spiritual ends." and Tube Feeding, in "Parameters in Health Care" 10 (Winter, 1985) 8-11; The A.M.A. In elaborating these criteria several document of the Church's Magisterium are quite relevant. There have been a total of 43 applications since 1992, all of which have been granted. The Royal College of Physicians' review began in May 2011, and is expected to last at least 18 months. The two researchers travelled all around the UK to talk to 65 people in their own homes. This document concluded: "We hold for a presumption in favor of providing medically assisted nutrition and hydration to patients who need it, which presumption would yield in cases where such procedures have no medically reasonable hope of sustaining life or pose excessive risks or burdens" (at 711). But the brain stem, which controls involuntary functions such as breathing, blinking, cycles of waking and sleeping, etc., is still functioning. But he has told the BBC of cases where families have been kept in the dark for years because of the religious, cultural or moral beliefs of the clinicians involved. There is also evidence families are not routinely being told of all the options open to them. Initially told the court process would take six months, the family was still no closer to a decision from the court 18 months later. I just have to turn my mind off because it affects me so much," she says. Therefore, if it is to be used for longer periods, it is done by inserting a tube into the central nervous system....This method of nutrition carries with it greater risks of complications.". The NHS is ready to use the initial 800,000 doses when they arrive, the health secretary says. Listen again via the BBC iPlayer or download the podcast. I don't like to say it, but it's true. "He will not be looked after properly. "Personally I'd like to see some clarity about what the pathway is. Terri Schiavo was an unfortunate young woman who suffered a cardiac arrest many years ago with subsequent brain damage from lack of oxygen. It is first of all important to have a correct understanding of what is meant by a "persistent vegetative state. Description. How the burden of caring for a patient in a vegetative state changes in relation to different coping strategies. Absence of awareness can only be inferred by lack of responsiveness to the environment and not as lack of consciousness that we may not be able to detect by behavioural measures. Patients who are in comas, or persistent vegetative states, require extensive care. 4In their Pastoral Letter of January 14, 1992, Nutrition and Hydration: Moral Considerations, in "Origins: NC News Service" 21 (January 30, 1992) 547, the Bishops of Pennsylvania ably summarize the different ways of supplying nourishment to the unconscious.