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In a vegetative state, actions are involuntary reflexes


Published March 24, 2005

What is a persistent vegetative state?

It's a condition in which people with severely damaged brains have no awareness of self or the environment around them. It is troublesome because lesser functioning parts of the brain continue to operate. People go to sleep, blink their eyes, focus on objects briefly, react to sounds and touch. But in a true vegetative state, these are involuntary reflexes and not reproducible, according to the American Academy of Neurology.

Florida law gives a specific definition: "The absence of voluntary action or cognitive behavior of any kind. An inability to communicate or interact purposely with the environment."

Why is this definition important?

Because brain-injured people like Terri Schiavo, who don't have living wills, cannot be deprived of life-prolonging procedures unless they meet the legal definition of persistent vegetative state.

Who decides?

Typically doctors and families quietly make these decisions. In rare cases, someone files a lawsuit and a judge must decide based on medical evidence.

What is a "minimally conscious state?"

Neurology, a journal, defines it as "inconsistent but clearly discernible behavioral evidence of consciousness." Distinguishing between vegetative and minimally conscious states can be very difficult, according to a 2000 Journal of Neuroscience Nursing article. It cited a 42 percent error rate in one study. Florida end-of-life law does not address minimally conscious states because it is such a recent concept. Schiavo had to meet the persistent vegetative standard to have her feeding tube removed.

Why did Gov. Jeb Bush suggest Wednesday that Schiavo may be minimally conscious?

Neurologist William Cheshire observed Schiavo on March 1 and reported that it is "more likely" that she is minimally conscious than in a vegetative state. She occasionally, but inconsistently, laughs when others in the room are laughing. She fixes her gaze on people and colorful objects for as long as 15 seconds. "There was a look of curiousity or expectation in her expression," Cheshire wrote. Most importantly, she appeared to feel discomfort on a videotape when a doctor rolled her on her back and poked her. The doctor says he wants to roll her over again and she grimaces and makes a crying sound.

"She appears to comprehend the meaning of (the doctor's) comment and signals her anticipation of pain," Cheshire wrote. "In summary, Terri Schiavo demonstrates behaviors in a variety of cognitive domains that call into question the previous neurological diagnosis of persistent vegetative state."

What do others say?

Early in the litigation, several doctors testified that Schiavo is in a vegetative state, which her parents did not dispute then. During a 2003 hearing, two doctors picked by the parents said she retained some level of cognition. Two doctors picked by her husband and one picked by the judge said she was in a vegetative state.

University of South Florida professor Jay Wolfson was appointed by the court as a guardian ad litem to conduct an independent review. He visited Schiavo every day for a month and supported the vegetative diagnosis. Schiavo "sometimes groans, makes noises that emulate laughter or crying, and may appear to track movement," Wolfson wrote, but her behavior was never consistent or purposeful.

Doesn't she smile at her mother and react to music?

Her parents and siblings say so, and Cheshire's report supports that notion. Wolfson, who spent hours watching her and her parents together, wrote "there was no success in eliciting specific responses."

Don't her brain scans confirm the diagnosis?

Doctors who diagnosed her in a persistent vegetative state cite CAT scans that show severe brain damage and fluid filling her cerebral cortex, which is one of the brain's higher-functioning centers. Cheshire recommended more sophisticated functional MRI or PET scans that can show if the cerebral cortex is reacting to language and other stimuli.

Times researcher Caryn Baird contributed to this report.

[Last modified March 24, 2005, 10:00:52]

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