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Coma Patient Wakes Up

New technique for brain injuries.
CLEVELAND — Had Terri Schiavo lived another 28 months, the latest medical breakthrough may have bolstered the hopes of those who defended her life.

A group of surgeons have restored the consciousness of a man who was in a coma-like “minimally conscious state” for six years, unable to feed himself or communicate. An article in the scientific journal Nature describes the work of a research team — led by Dr. Ali Rezai, director of the Center for Neurological Restoration at the Cleveland Clinic.

The study involved the 2005 surgical installation of two electrodes in the brain of a male trauma victim.

“It’s a promissory note on the future that will hopefully be brighter for people with severe brain injuries,” said Dr. Joseph Fins, chief of the division of medical ethics at Weill Medical College of Cornell University and co-author of the study.

The electrodes, powered by a pacemaker battery in the man’s chest, provide mild deep-brain electrical stimulation the doctors say opens the door to treatment of severe brain injuries traditionally considered hopeless.

Immediately after the electrodes were turned on, the man opened his eyes. Today, he feeds himself and communicates with family members from his hospital bed. He has made slow but continuous progress, though he’s far from his pre-injury condition and lacks the physical strength to walk.

Dr. Joseph Giacino, co-leader of the study and associate director of the New Jersey Neuroscience Institute, said nothing about the procedure could be made public for the past two years because it first needed peer review for publication in a medical journal.

The patient, a 38-year-old man who suffered brain injuries from a brutal assault, remains under Giacino’s direct care. He said family members have requested strict anonymity for the patient and themselves.

“We believe we’ve presented evidence that we can bring about recovery from severe brain injury,” Giacino said. “This man was six years post injury, and that really gives us good cause for optimism. It says we can alter the course of recovery, and we can do it late.”

Though the breakthrough raises questions about Schiavo — whose brain injury caused worldwide debate when her husband demanded that doctors remove tubes that were providing nutrition and hydration, Giacino said his patient’s circumstances were different than Schiavo’s.

Much of the distinction between Schiavo and the study patient involves a gray area that separates patients in what’s known medically as a “vegetative” state and a “minimally conscious” state. Neither condition is a coma, which involves complete unconsciousness and seldom lasts more than four weeks.

Giacino led the Aspen Neurobehavioral Conference Workshop, in which a group of doctors defined the “minimally conscious” condition in 1997, which became a diagnostic term with peer-reviewed publication in 2002. Giacino said his study patient was clearly in a “minimally conscious” state, while it remains unclear to him whether Schiavo was “minimally conscious” or “vegetative.”

“I don’t know what state Terri Schiavo was in, to be honest, because we did not have enough information before she died,” Giacino said.

Though Schiavo left no living will, Michael Schiavo, insisted he recalled conversations that made it clear the woman would never want the assistance of medically-delivered water and food.

Michael Schiavo chose neurologist Ronald Cranford to examine his wife and testify in court that the she was in a “permanent vegetative state.” Cranford, a right-to-die activist, is a member of the board of directors of the Choice in Dying Society and was a speaker at the 1992 national conference of the Hemlock Society, known today as End of Life Choices.

Though Cranford insisted Schiavo was permanently vegetative, William Hammesfahr, a Florida neurologist who spent 10 hours observing Schiavo, insisted she was in a minimally conscious state — just like the patient in the electrode study. She died March 31. 2005.

Even if Hammesfahr was correct, said Giacino, Terri Schiavo wouldn’t have benefited from electrodes at this time because her injury wasn’t caused by blunt trauma. Rather, he said, Schiavo’s injury involved oxygen deprivation resulting from a heart attack.

“At this stage, this procedure will not help patients suffering from anoxic (oxygen deprivation) injuries,” Giacino said. “We can conceive that in the future we may be able to go down the ladder, to include people with other conditions. But for this study, we were looking for someone who met a very specific set of criteria and I know from Terri Schiavo’s autopsy report that she would not have met those and the electrode wouldn’t have helped.”

Fins, of Weill Medical College of Cornell University, said Schiavo was part of a deep-brain implant study in the early 1990s, conducted on about 50 patients, and it failed.

“It didn’t help her because she wasn’t minimally conscious, she was vegetative,” Fins said. “Our study involves a population in a different brain state, which was identified and defined by Dr. Giacino’s group.”

Fins said he hopes the implant study helps reverse what he calls an attitude of “therapeutic nihilism” regarding brain injuries. However, he’s also concerned it may cause false hope for mass recoveries in the near future.

He warned that the study, which the FDA has approved for only 11 patients, represents the infant stages of a possible procedure that may someday be widely available, but only if it continues as safe and successful in scores of additional studies.

“It remains extraordinary at this point,” Fins said. “Will it complicate conversations? Yes, and that’s a good thing. There should be more gut-busting choices out there when it comes to patients in the minimally conscious state. When a doctor says ‘there’s no hope for meaningful recovery,’ you want to define what ‘hope’ and ‘meaningful’ mean to you and the patient.”

The patient who received the successful stimulator implant remains disabled, but his mother views the recovery as meaningful.

At a press conference announcing the Nature article, the mother said her son watches movies, enjoys meals, laughs, cries and expresses love.

“I still cry every time I see him, but now it’s tears of joy,” she said.

“I had tears in my eyes after she spoke,” Fins said.

The medical community has no solid figures, but Fins said estimates based on extrapolation have placed the number of U.S. patients in minimally conscious states as high as 280,000 and as low as 114,000.

“A lot of these patients are the subjects of life and death decisions by their families,” said Giacino, explaining that often the food and water tubes are removed with no public fanfare.

Ian Greenfield, director of communication for Compassion and Choices in Denver, the largest “choice in dying” organization in the United States, said the successful implants in one study patient shouldn’t alter one’s decision to honor the wishes a severely brain-injured patient may have expressed or written regarding life support prior to the injury.

“One has to be careful about heartening stories regarding one or a few people,” Greenfield said. “We have to be careful that these decisions are not based on whatever’s happening in the media at that moment, but rather on the desire of the patient as it was hopefully expressed before the injury.”

John Brehany, a medical ethicist and executive director of the Catholic Medical Association, said Church teaching holds that anyone in a condition the medical field would describe as “minimally conscious” should receive food and water regardless of breakthroughs, potential recoveries and predictions about post-recovery quality of life. He hopes the successful electrodes implant will help people make life-preserving decisions about patients with severe brain injuries.

“The issues that typically short circuit good ethical decisions are emotional sadness, depression and confusion that result when we think or are told that nothing can be done,” Brehany said. “These feelings tend to freeze people and cause them to give up.”

Though experts continue debating whether Schiavo was in a vegetative or minimally conscious state, Brehany doesn’t think the latest medical development regarding severe brain injuries would have prevented or delayed the deprivation of food and water that caused her death.

“Before her death, people were suggesting a new therapy called Functional MRI, in which doctors could determine her brain activity by watching her response to specific stimuli,” Brehany said. “That would have told us a lot about her real condition at the time. But the husband and the courts were driven to carry out what they said was her wish that none of it be done.”

Wayne Laugesen is based in Boulder, Colorado.

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