End of Life March 31, 2009

Persistent Vegetative State  “People diagnosed with PVS have damaged or dysfunctional cerebral hemispheres, and this results in their not being aware of themselves or their surroundings. They are incapable of thinking and of deliberate or intentional movement.”  Brainstem is preserved  “Persistent” after four weeks; if no change after three months, unlikely to recover  Breathe  Excrete  Hearts beat  Muscles move (reflex)  Sleep-wake patterns  Eyelids blink and Eye move, but no vision  Smile (reflex)  Tears (reflex) -Munson, Ronald, ed. Interventions and Reflections. p  “People diagnosed with PVS have damaged or dysfunctional cerebral hemispheres, and this results in their not being aware of themselves or their surroundings. They are incapable of thinking and of deliberate or intentional movement.”  Brainstem is preserved  “Persistent” after four weeks; if no change after three months, unlikely to recover  Breathe  Excrete  Hearts beat  Muscles move (reflex)  Sleep-wake patterns  Eyelids blink and Eye move, but no vision  Smile (reflex)  Tears (reflex) -Munson, Ronald, ed. Interventions and Reflections. p. 676.

Minimally Conscious State  Show some awareness  Awake  Minimal responsiveness  Greater activity in cerebral cortex than that of PVS  “…demonstrate one or more of four types of behaviors on a reproducible or sustained basis: following simple commands; gestural or verbal yes/no responses; intelligible verbalization; and purposeful (as opposed to reflexive) behavior.” -Eisenberg  Show some awareness  Awake  Minimal responsiveness  Greater activity in cerebral cortex than that of PVS  “…demonstrate one or more of four types of behaviors on a reproducible or sustained basis: following simple commands; gestural or verbal yes/no responses; intelligible verbalization; and purposeful (as opposed to reflexive) behavior.” -Eisenberg

Locked-in Syndrome  “Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement. It may result from traumatic brain injury, diseases of the circulatory system, diseases that destroy the myelin sheath surrounding nerve cells, or medication overdose. Individuals with locked-in syndrome are conscious and can think and reason, but are unable to speak or move. The disorder leaves individuals completely mute and paralyzed. Communication may be possible with blinking eye movements”  kedinsyndrome.htm  “Locked-in syndrome is a rare neurological disorder characterized by complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement. It may result from traumatic brain injury, diseases of the circulatory system, diseases that destroy the myelin sheath surrounding nerve cells, or medication overdose. Individuals with locked-in syndrome are conscious and can think and reason, but are unable to speak or move. The disorder leaves individuals completely mute and paralyzed. Communication may be possible with blinking eye movements”  kedinsyndrome.htm

What can brain scans tell us?  Images Images  Video Video  Images Images  Video Video

Four concepts of Death 1.Traditional: no longer breathing and heart is not beating (“cardiopulmonary”) 2.Whole-brain: irreversible cessation of brain function (no electrical activity, no brain stem function) 3.Higher-brain: permanent loss of consciousness; brain stem continues to regulate breathing and heartbeat 4.Personhood: individual ceases to be a person (usually includes criteria such as reasoning, remembering, emotional response, sense of the future, interacting, etc.) Munson, Ronald, ed. Interventions and Reflections. P Traditional: no longer breathing and heart is not beating (“cardiopulmonary”) 2.Whole-brain: irreversible cessation of brain function (no electrical activity, no brain stem function) 3.Higher-brain: permanent loss of consciousness; brain stem continues to regulate breathing and heartbeat 4.Personhood: individual ceases to be a person (usually includes criteria such as reasoning, remembering, emotional response, sense of the future, interacting, etc.) Munson, Ronald, ed. Interventions and Reflections. P

What counts as humanity? 1.“Consciousness (of objects and events external and/or internal to the being), and in particular the capacity to feel pain” 2.“reasoning (the developed capacity to solve new and relatively complex problems)” 3.“Self-motivated activity (activity which is relatively independent of either genetic or direct external control)” 4.“the capacity to communicate, by whatever means, messages of an indefinite variety of types, that is, not just with an indefinite number of possible contents, but on indefinitely many possible topics” 5.The presence of self-concepts, and self-awareness, either individual or racial, or both” -Warren, Mary Anne. “On the Moral and Legal Status of Abortion.” Intervention and Reflection. Ronald Munson, ed. p “Consciousness (of objects and events external and/or internal to the being), and in particular the capacity to feel pain” 2.“reasoning (the developed capacity to solve new and relatively complex problems)” 3.“Self-motivated activity (activity which is relatively independent of either genetic or direct external control)” 4.“the capacity to communicate, by whatever means, messages of an indefinite variety of types, that is, not just with an indefinite number of possible contents, but on indefinitely many possible topics” 5.The presence of self-concepts, and self-awareness, either individual or racial, or both” -Warren, Mary Anne. “On the Moral and Legal Status of Abortion.” Intervention and Reflection. Ronald Munson, ed. p. 591.

Infant “personhood” Three considerations: 1.How much neurological development is required for personhood? 2.How much neurological impairment is necessary to rule out personhood? 3.Is any significance to be placed on the principle of potentiality as it applies to personhood? -Weir, Robert. “Life-and-Death Decisions in the Midst of Uncertainty.” Interventions and Reflections. Ronald Munson, ed. p Three considerations: 1.How much neurological development is required for personhood? 2.How much neurological impairment is necessary to rule out personhood? 3.Is any significance to be placed on the principle of potentiality as it applies to personhood? -Weir, Robert. “Life-and-Death Decisions in the Midst of Uncertainty.” Interventions and Reflections. Ronald Munson, ed. p. 651.

Patient’s Best Interests Standards 1.Severity of the patient’s medical condition 2.Availability of curative or corrective treatment 3.Achievability of important medical goals 4.Presence of serious neurological impairments 5.Extent of the infant’s suffering 6.Multiplicity of other serious medical problems 7.Life expectancy of the infant 8.Proportionality of treatment-related benefits and burdens to the infant -Weir, Robert. “Life-and-Death Decisions in the Midst of Uncertainty.” Interventions and Reflections. Ronald Munson, ed. p Severity of the patient’s medical condition 2.Availability of curative or corrective treatment 3.Achievability of important medical goals 4.Presence of serious neurological impairments 5.Extent of the infant’s suffering 6.Multiplicity of other serious medical problems 7.Life expectancy of the infant 8.Proportionality of treatment-related benefits and burdens to the infant -Weir, Robert. “Life-and-Death Decisions in the Midst of Uncertainty.” Interventions and Reflections. Ronald Munson, ed. p. 655.

So how does this compare to abortions?  “A being who has had experience, has lived and suffered, who possesses memories, is more human than one who has not. Humanity depends on formation by experience.”  Noonan, John T. “An Almost Absolute Value in History.” Intervention and Reflection. Ronald Munson, ed. p. 574  “A being who has had experience, has lived and suffered, who possesses memories, is more human than one who has not. Humanity depends on formation by experience.”  Noonan, John T. “An Almost Absolute Value in History.” Intervention and Reflection. Ronald Munson, ed. p. 574

Another view…  “Take, for example, the most common argument. We are asked to notice that the development of a human being from conception through birth into childhood is continuous…”  Thomson, Judith Jarvis. “A Defense of Abortion.” Intervention and Reflection. Ronald Munson, ed. p. 577  “Take, for example, the most common argument. We are asked to notice that the development of a human being from conception through birth into childhood is continuous…”  Thomson, Judith Jarvis. “A Defense of Abortion.” Intervention and Reflection. Ronald Munson, ed. p. 577

fMRI and Terri Schiavo  Help determine diagnosis of PVS versus MCS instead of just behavioral diagnosis  Help make end-of-life decisions  Help determine diagnosis of PVS versus MCS instead of just behavioral diagnosis  Help make end-of-life decisions

Case Presentation- Helga Wanglie Family vs. Physicians (two groups) -Define the family’s point of view and decide what else could support this opinion -Define the physician/hospital point of view and decide what else could support this opinion Family vs. Physicians (two groups) -Define the family’s point of view and decide what else could support this opinion -Define the physician/hospital point of view and decide what else could support this opinion

Deep Brain Stimulation  Dr. Nicholas Schiff, Time ArticleArticle  Banjo Clip Banjo Clip  Dr. Nicholas Schiff, Time ArticleArticle  Banjo Clip Banjo Clip