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From Nature magazine
Adrian Owen still gets animated when he talks about patient 23. The patient was only 24 years old when his life was devastated by a car accident. Alive but unresponsive, he had been languishing in what neurologists refer to as a vegetative state for five years, when Owen, a neuro-scientist then at the University of Cambridge, UK, and his colleagues at the University of Liège in Belgium, put him into a functional magnetic resonance imaging (fMRI) machine and started asking him questions.
Incredibly, he provided answers. A change in blood flow to certain parts of the man's injured brain convinced Owen that patient 23 was conscious and able to communicate. It was the first time that anyone had exchanged information with someone in a vegetative state.
Patients in these states have emerged from a coma and seem awake. Some parts of their brains function, and they may be able to grind their teeth, grimace or make random eye movements. They also have sleep–wake cycles. But they show no awareness of their surroundings, and doctors have assumed that the parts of the brain needed for cognition, perception, memory and intention are fundamentally damaged. They are usually written off as lost.
Owen's discovery, reported in 2010, caused a media furore. Medical ethicist Joseph Fins and neurologist Nicholas Schiff, both at Weill Cornell Medical College in New York, called it a “potential game changer for clinical practice”. The University of Western Ontario in London, Canada, soon lured Owen away from Cambridge with Can$20 million (US$19.5 million) in funding to make the techniques more reliable, cheaper, more accurate and more portable — all of which Owen considers essential if he is to help some of the hundreds of thousands of people worldwide in vegetative states. “It's hard to open up a channel of communication with a patient and then not be able to follow up immediately with a tool for them and their families to be able to do this routinely,” he says.
Many researchers disagree with Owen's contention that these individuals are conscious. But Owen takes a practical approach to applying the technology, hoping that it will identify patients who might respond to rehabilitation, direct the dosing of analgesics and even explore some patients' feelings and desires. “Eventually we will be able to provide something that will be beneficial to patients and their families,” he says.
Still, he shies away from asking patients the toughest question of all — whether they wish life support to be ended — saying that it is too early to think about such applications. “The consequences of asking are very complicated, and we need to be absolutely sure that we know what to do with the answers before we go down this road,” he warns.
Lost and found
With short, reddish hair and beard, Owen is a polished speaker who is not afraid of publicity. His home page is a billboard of links to his television and radio appearances. He lectures to scientific and lay audiences with confidence and a touch of defensiveness.
Owen traces the roots of his experiments to the late 1990s, when he was asked to write a review of clinical applications for technologies such as fMRI. He says that he had a “weird crisis of confidence”. Neuroimaging had confirmed a lot of what was known from brain mapping studies, he says, but it was not doing anything new. “We would just tweak a psych test and see what happens,” says Owen. As for real clinical applications: “I realized there weren't any. We all realized that.”
Owen wanted to find one. He and his colleagues got their chance in 1997, with a 26-year-old patient named Kate Bainbridge. A viral infection had put her in a coma — a condition that generally persists for two to four weeks, after which patients die, recover fully or, in rare cases, slip into a vegetative or a minimally conscious state — a more recently defined category characterized by intermittent hints of conscious activity.
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24 Comments
Add CommentI couldn't be bothered to closely read the entire article, but it sounds like this entire article and funding has been granted due to one patient answering 5 of 6 questions correctly. Is that correct?
Reply | Report Abuse | Link to thisI've heard that fMRI are also useful for detecting brain activity in dead salmon.
The naysayers seem to have a weirdly unscientific approach, at least if we can judge by the information given in this article.
Reply | Report Abuse | Link to thisFrom the article: "The result, published in a one-page article in Science, evoked wonder and disbelief. “I got two types of e-mail. People either said 'this is great' or 'how could you possibly say this woman is conscious?',” Owen says."
Judging by the article, Adrian Owen has some fairly significant evidence that the patients may be conscious. It's not conclusive proof, but he does have evidence pointing clearly in that direction. What evidence do the naysayers have? What do they base their naysaying on? Guessing?
I hope the discussion on this subject is based on something more firm than pure guesswork. I wish the article had given some clue about the reasons for the naysayers' conclusions.
Actually, I'm rather perplexed that the EEG communication trick isn't already routine for all these patients from years ago. Why not? It's a rather obvious thing to try.
GeekStatus, there's far more to it. You can't judge the article without reading it.
Reply | Report Abuse | Link to thisCould the reason for the naysaying be that some people find the idea of a conscious vegetative state so scary that they just can't think straight?
Reply | Report Abuse | Link to thisIf so, it probably becomes much easier if you try to calmly think about what your interests would be, what you'd be curious about, if you had to receive all information passively all the time.
For me, one thing is certain, I'd definitely want to stay alive. But then I'm an incurable optimist and very upbeat, despite already having an illness that limits my life extremely. You can still have fun, if you know how to look for it.
If I were in a conscious vegetative state, I'd prefer to listen to the radio about 3/4 of my waking time, with news and calm, upbeat music. The ideal would be to also hear radio programs about the subjects that interest me most, such as science and technology. The rest of the time, very roughly 1/4 of my waking time, I'd prefer quiet, for my own thinking.
Ideally this would be sprinkled with communication using some trick, like the article's EEG trick if nothing else works. In this context I'd prefer that the staff help me learn the Morse alphabet, or some other suitable alphabetic mode. Since this spelling mode will be very slow, they could go about their business while I spell out letters on a computer.
The world-famous physicist Stephen Hawking is completely paralyzed except for a single cheek that he can twitch very slightly. Surprisingly, this is enough for extensive communication and an active life. And he has expressed great gratitude for being alive!
So don't be too scared of these things. Don't assume that a severely limiting illness must necessarily be the end of everything. It's certainly a major catastrophe when it happens, but, given time, you learn your way in the new situation. There are good things still, once you discover how to look for them.
Putz. You can't be bothered to study the article. Yet you have an opinion about second hand information you've heard elsewhere about fMRI and dead salmon? Putz. And you're apparently worried that your precious tax dollars might be spent on a grant for research into something you couldn't be bothered to carefully read? Conservatard putz. Republican't flat-earther. Stay away from scientific-inclined websites. Instead, to go biblically inclined websites, where you can find your own kind and post positive comments, ill-informed though they will be. Mythologically based putz. Repugnicant, bronze-age tax whiner. Repulsivant climate-change denier. Go see the Wizard of Oz about getting a brain, a new heart, and some courage. Then come back to this website.
Reply | Report Abuse | Link to thisA suggestion for Adrian Owen.
Reply | Report Abuse | Link to thisThe article discusses the problem of asking conscious vegetative patients if they want their life support to continue or not. In my opinion you should never, ever ask them this question.
Some patients would feel quite strongly that they are a terrible burden, and that therefore they have an obligation to stop being such a burden. Many patients will be depressed and highly vulnerable, and due to their lack of social interaction they'll be easily agitated and unbalanced. The communication doesn't allow for nuances. There's no way to detect such feelings. Just don't.
Instead, once some simple communication is functioning, and the time is ripe, give the patients some arrangement for alphabetic and word-coded communication, so they can create their own sentences. Then the patients themselves can bring the subject up, if they feel so inclined.
Most patients probably won't feel so inclined if you can successfully focus on how to satisfy their interests and curiosity. One example would be the radio programs I mentioned in my previous comment. Also, if you can set up alphabetic communication through a computer, access to the Internet might become possible, perhaps with a voice-reading browser for the blind. This would open up possibilities for the patient to take their own initiatives in order to explore and learn interesting things, which is hugely valuable when your life is very limited. It makes a tremendous difference.
Alphabetic and word-coded communication also has the advantage that if patients produce coherent sentences, this gives strong proof of consciousness.
Oh, and one more thing. Remember that neurological problems can be extremely exhausting for the patient. You should probably make the communication sessions very short in the beginning, and let the patients get used to them through a very slow increase day after day.
Kafpauzo, regarding the ultimate question of life or death. I wholeheartedly disagree with your comments!
Reply | Report Abuse | Link to thisIf I was in a "locked-in" state, I would want my feelings on this issue to be known. I don't, at this point in my life, know what my answer would be BUT I would like the question asked. I would like to make the decision regarding my life or death, if it came to this, rather than some uniformed person making it for me.
As for GeekStatus... total waste of his/her and our time.
Bwana, if they give you an alphabetic and word-code mode of communication, this means that you can write your own sentences. In these sentences you can speak your mind. You can say whatever you like, just like you made your opinion known in your comment.
Reply | Report Abuse | Link to thisMy point is that it should be _you_ who choose to bring this up. It shouldn't be thrown upon you by somebody else at some random moment, when you may be unprepared, sensitive, vulnerable, depressed, or something. It's up to _you_ to choose when you want to deal with this issue.
If I'm in that utterly powerless state, I certainly don't want to hear questions that sound like hints that I'm too much of a burden and they'd prefer that I die. If I discover that I want to die, it's _my_ choice to bring this up at the time that _I_ prefer.
It's too sensitive an issue to be brought up by anyone but the patient himself.
Also, if the patient himself/herself writes a fully coherent sentence such as "I don't want to live like this, I want this to end, please turn off my life support machines," then this is a much clearer indication of what the patient actually wants, than if the doctor asks questions and the patient can only give one of two coded signals for "yes" or "no".
Reply | Report Abuse | Link to thisIn the latter case you can never be fully certain that the patient has actually understood the questions and made a clearly informed, voluntary choice. The patient might be too exhausted, or too confused, or too high on painkillers, or anything.
This is of course also possible when the patient says what he wants in his own words, but then the patient's actual will plays a much clearer role. Such sentences can't be a series of misunderstandings or coincidences.
After the patient has broached the subject, if the subject is discussed several times on different days, in the end you have a far higher certainty that you know what the patient actually wants.
Kafpauzo
Reply | Report Abuse | Link to this'if they give you an alphabetic and word-code mode of communication, this means that you can write your own sentences'.
My partner suffered traumatic brain injury many years ago (before I met him) but has total comprehension. He can't readily vocalise and has severe cognitive disabilities, the latter rendering him unable to utilise the type of communication you mention. I think it's rather patronising that you should expect someone like him to 'conform' to your method. He has cleverly devised his own ways of communicating which are rather effective, certainly to those who are open to alternative methods of receiving information. When I first met him, I asked him if he wished he'd been allowed to die and he replied in the affirmative. If someone can't initiate conversation themselves, it is only right that they should be given the opportunity to express themselves by broaching the question. It's not about avoiding the issue Kafpauzo, it's about how one sensitively goes about it. Years later when we had developed a loving relationship, I asked the question again and despite a very uncomfortable existence, he was definite in his reply, that he wants to live. Like most of us, he only needed something to live for! We have just had a Blessing to affirm our commitment to each other. Too many people, lay and professional alike, are too quick to 'write people off'just because they do not fit in with our norms. What I can't comprehend is that there are not more people like Owen, caring, inquisitive and innovative, who would seek to find answers. I wished he worked in our locality; I've not met a professional here who is fascinated enough to explore any advancements, in any area of my partner's brain development. Such a waste of opportunities!
Zam, obviously I was talking about the case where you find that the patient can successfully form sentences.
Reply | Report Abuse | Link to thisWhen you find that a patient can successfully form sentences and express his will and take the initiative, then you let him take the initiative. I'd say it's patronising _not_ to let a person take the initiative when he can, it's patronising to step in and decide over a person's head, ignoring his ability to take the initiative.
In the very different case where a patient is not able to form sentences, obviously you don't stand there passively waiting for him to somehow form sentences anyway. We're talking about a hospital context, where there are neurologists and others who know perfectly well that aphasias and other problems can cause a large number of different limitations.
Obviously you have to work with what is possible for each patient individually.
But I also really do feel that the people around these patients should explore ways to give the patients something to live for. It's not enough to let these patients suffer through months of total passivity, and then ask them if they want to either end life support or keep suffering total passivity.
Some of these patients may want to cultivate an interest in classical music, or surf the Web learning about various subjects, or slowly write a book letter by letter. It's impossible for the locked-in patient to explore the various possibilities without help and encouragement from the people around them.
That's where you should invite the patient to explore possibilities. Inviting him to die is something you only do if he can't broach the subject himself, and only after inviting him to try many options for enjoyment, exploration, writing etc, exploring what each patient finds possible and interesting.
I fully agree with you in wishing that there were more people like Adrian Owen, exploring important matters like this one. I really don't understand why people don't try that simple EEG trick for communication.
2 years ago, I was in a coma (caused by HELLP Syndrome) for 4 weeks, hooked up to life support. Prior to this event I had shared a New Yorker Magazine article with my husband about patients in persistent vegetative states who showed significant brain activity during an EEG when a loved one talked them through a favorite sports activity. So my husband asked for an EEG and requested to be present. The technician was very strict: my husband had to sit 5 feet away from me and was only allowed to talk at certain moments...the test was long and so my husband had to talk for several hours. He talked me through some of our favorite hikes, horse back riding lessons, etc. & a few days later, the doctors conceded that the results were "surprisingly active" & they stopped trying to lower his expectations for my recovery. However, I was blessed in that I had dual, union provided health insurance that paid for brain surgery as well as 18 months of cognitive & physical therap(ies) --- all of which totaled more than $2 million. I won't lie; my recovery has not been easy. It takes a lot of work to resume normal functioning. But I agree that brain injuries are not all the same and that the treatment works best if it adapts to the individual patient's needs. I saw a lot of patients who were worse off than I was & I still grieve over their situations. I also saw a lot of treatment that I thought discounted patients' feelings and needs. Just because a patient is brain injured & has trouble communicating does not mean that all of their emotions are mere "reflexes." Some of these patients are genuinely grieving. We need to revise our understanding of consciousness & incorporate recent discoveries about it into our treatment of the brain injured.
Reply | Report Abuse | Link to thisDue to the brain injury I was not able to live at home with my husband and new baby for six months. My husband petitioned insurance to cover the home health care we needed while he worked full time. Insurance (which would have paid to keep me in the residential facility) denied his request so he brought me home and paid for the care we needed himself. For this (and many other things) my husband will forever be my hero. Though I have made an excellent recovery I will probably always grieve the months I missed with my new daughter. I am determined to miss out on no more time with her and to help educate others about brain injury and become an advocate on behalf of the brain injured.
What checks are made for consciousness before deciding on organ donation?
Reply | Report Abuse | Link to thisIs it possible that patients who are kept going on life support may be conscious, even though they seem to be brain dead?
With so many people now registered as organ donors (in New Zealand, on their driving licences) could a sad mistake be made?
Great work,but the job now is finding the triggers that brings people out of comas.We know that some people just wake up and we need to look at what was going on in thier brains when this happens .Knowing what is happening could lead to treatments that can awaken those that are in comas.
Reply | Report Abuse | Link to thisGr8 Dr.Adrian Owen!
Reply | Report Abuse | Link to thisAs a Senior Consultant Neurosurgeon I can foresee the impact of your work, whatever the less involved / affected naysayers may say!
Let the caravan go on!
Godspeed!
Why are there so many moronic trolls on the Internet these days?
Reply | Report Abuse | Link to thisWork like this shows the uncertainty of the interface between cognition and unconscious/conscious interface
Reply | Report Abuse | Link to thismy own fairly simple work many years ago showed learning took place under anaesthesia .
Ive always been of the opinion that, though very pro organ donation , that brain stem death criteria positive patients should have a GA before organ harvest for the same reason
Raj
Well now! I don't think I've ever read a more thorough insult. I just hope your effort was not wasted.
Reply | Report Abuse | Link to thisWell, it depends whois reading the results; no transplant surgeon reading such results has ever found such a potential donor "at home".
Reply | Report Abuse | Link to thisGET OFF !
Reply | Report Abuse | Link to thisIf alternate communication is exchanged with these individuals, then the life or death questions would not apply here, the person is not incoherent, and would this not turn into assisted suicide, as in asking the patient WHAT they would want??? Further or any comments welcome!
Reply | Report Abuse | Link to thisMrgwer, that is indeed an interesting question.
Reply | Report Abuse | Link to thisI don't know if turning off life support legally counts as suicide / assisted suicide / murder. In the case where you turn it off based on the patient's request, I think it's forbidden in almost all countries, but not all.
But since the discussion here was based on an assumption that a desire to die should be found out, respected and acted upon, I chose to ignore this thorny issue, and just go along with this apparent basis of the discussion.
Personally, I get the impression that, practically always, when someone wants to die, the real problem is that he believes that he has nothing to live for, or believes that he is despised and hated by all, or suffers from extreme pain or extreme anxiety, and so on. The correct thing to do, in my view, is to help him discover that, on the contrary, he has a lot to live for, or he is respected and loved, or to treat his pain or his anxiety, and so on. You should do something about the real problem, rather than kill the person.
I get the impression that people who have wanted to die, but survive, with time almost invariably mature into a completely different state, where they can enjoy life. They find happiness and enjoyment, and are glad to be alive. As I see it, when they are glad to be alive, this means they are glad that they are still alive, which they wouldn't be if they had died back when they wanted to.
Proponents of assisted suicide say that my attitude means that I disrespect these people's desire to die. Me, I think that my attitude means that I want to solve the real problem, in a manner that gives joy and happiness, rather than focus on a secondary symptom, in a manner that is deadly.
But it's certainly a thorny issue, where many different arguments are possible.
Here is a recent account of the practice of at the Neurosciences Critical Care Unit (NCCU) at Addenbrooke's Hospital in Cambridge England which discusses how the issue of life and death are dealt by medics, relatives and a patient. This is in the context of England's National Health Service.
Reply | Report Abuse | Link to thishttp://www.bbc.co.uk/blogs/tv/2010/07/between-life-and-death-why-med.shtml
My 78-yo sister in law died this morning during a ventricular-fibrillation event, 3-months after a right hemisphere stroke left her without speech, recognition ability, movement on her left side, and likely awareness of her situation. During those months she rotated back and forth from the ER to the ICU, to rehab and recovery, and to a nursing home where physical and speech therapy were attempted. Of her 5-sisters my wife spent the most time with her (3-8 hours daily) and was on a roller coaster of emotion as her sister seemingly responded to simple commands, smiled, tried to talk, but then suffered several setbacks caused by infection and fevers. Not once though did she ever respond to a direct question with a hand squeeze even though she would grasp an offered hand tightly. My wife would have given anything to know what she was thinking, if she recognized her, and was aware of her surroundings. For those who have been through event such as this knowing a patient's mental state would be infinitely helpful especially when it comes down to the life and death decision to resuscitate.
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