How Can We Tell If A Comatose Patient Is Conscious
Neurologist Steven Laureys looks for signs of consciousness in unresponsive patients
Steven Laureys greets me with a smile as I enter his office overlooking the hills of Liège. Although his phone rings constantly, he takes the time to talk to me about the fine points of what consciousness is and how to identify it in patients who seem to lack it.
Doctors from all over Europe send their apparently unconscious patients to Laureysa clinician and researcher at the University of Liègefor comprehensive testing. To provide proper care, physicians and family members need to know whether patients have some degree of awareness. At the same time, these patients add to Laureys understanding. The interview has been edited for clarity.
What is consciousness?
It is difficult enough to define life, even more so to define conscious life. There is no single definition. But of course, in clinical practice we need unambiguous criteria. In that setting, everyone needs to know what we mean by an unconscious patient. Consciousness is not all or nothing. We can be more or less awake, more or less conscious. Consciousness is often underestimated much more is going on in the brains of newborns, animals and coma patients than we think.
So how is it possible to study something as complex as consciousness?
What processes in the brain create consciousness?
What happens in a comatose person?
How do we know whether a coma patient who has awakened is conscious?
Thoughts From Families Who Have Been There
Family members who have a loved one in a minimally conscious or vegetative state have identified a number of important issues:
It might not be possible to find someone who knows everything about how to access these various services and programs. The key is to keep asking questions and following up to make sure that you and your loved one get all the benefits that are available. People who may be helpful to you are social workers, therapists, case managers, the local social security office, your state brain injury association chapter, family members or friends who are disabled or who have family who are disabled, or the human resources department at your loved ones employer.
Spontaneous Movements Often Occur After Brain Death
- American Academy Of Neurology
- Many brain-dead patients have spontaneous movements such as jerking of fingers or bending of toes that can be disturbing to family members and health care professionals and even cause them to question the brain-death diagnosis. These movements occur in 39 percent of brain-dead patients, according to a study published in the January 11 issue of Neurology, the scientific journal of the American Academy of Neurology.
ST. PAUL, MN – Many brain-dead patients have spontaneous movements such as jerking of fingers or bending of toes that can be disturbing to family members and health care professionals and even cause them to question the brain-death diagnosis. These movements occur in 39 percent of brain-dead patients, according to a study published in the January 11 issue of Neurology, the scientific journal of the American Academy of Neurology.
We found that these movements are more common than has been reported or believed, said neurologist and study author José Bueri, MD, of J. M. Ramos Mejia Hospital in Buenos Aires, Argentina. People need to know that these movements are spinal reflexes that do not involve any brain activity.
The study examined all patients at the hospital during an 18-month period with a diagnosis of brain death. Of the 38 patients, 15 had these motor movements. In all cases, the movements were seen in the first 24 hours after brain death diagnosis, and no movements were seen after 72 hours.
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Donation After Brain Death
Families of a brain dead patient must, by federal regulations, be provided the option of organ donation. If the family declines donation, the mechanical ventilator, medications and fluids are discontinued, after which the heart stops. If the family says yes to donation, the regional organ procurement organization is involved. The donors body is kept functioning by artificial means, such as ventilated support until the recovery of organs and tissue for life-saving transplant.
If you support donation it is important to document your decision. This removes the burden off of your loved ones to make the decision once you have passed away.
Causes Of Brain Death
Brain death can happen when the blood and/or oxygen supply to the brain is stopped.
This can be caused by:
- cardiac arrest when the heart stops beating and the brain is starved of oxygen
- a heart attack when the blood supply to the heart is suddenly blocked
- a stroke when the blood supply to the brain is blocked or interrupted
- a blood clot a blockage in a blood vessel that disturbs or blocks the flow of blood around your body
Brain death can also be caused by:
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How Long Will A Brain
A 13-year-old girl in California continues to be on a ventilator after being declared brain-dead by doctors. Although a brain-dead person is not legally alive, how much of the body will keep on working with the help of technology, and for how long?
Jahi McMath of Oakland, Calif., was declared brain-dead last month after experiencing an extremely rare complication from tonsil surgery. Jahi’s family members have fought to keep their daughter on a ventilator, but a judge has ordered that the machine be turned off next week.
A person is considered brain-dead when he or she no longer has any neurological activity in the brain or brain stem meaning no electrical impulses are being sent between brain cells. Doctors perform a number of tests to determine whether someone is brain-dead, one of which checks whether the individual can initiate his or her own breath, a very primitive reflex carried out by the brain stem, said Dr. Diana Greene-Chandos, an assistant professor of neurological surgery and neurology at Ohio State University Wexner Medical Center. “It’s the last thing to go,” Greene-Chandos said.
In the United States and many other countries, a person is legally dead if he or she permanently loses all brain activity or all breathing and circulatory functions. In Jahi’s case, three doctors have concluded that she is brain-dead.
With just a ventilator, some biological processes including kidney and gastric functions can continue for about a week, Greene-Chandos said.
What Does Brain Death Mean
Brain death is a legal definition of death. It is the complete stopping of all brain function and cannot be reversed. It means that, because of extreme and serious trauma or injury to the brain, the body’s blood supply to the brain is blocked, and the brain dies. Brain death is death. It is permanent.
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Reversing Brain Death: Far
From gene editing to human head transplantation, the limits of medical science are being pushed further than ever. And now, researchers have turned their attention to another extraordinary mission: reversing brain death.
Though it sounds similar to the makings of fiction, scientists have received approval for the first ever trial that aims to restore neuronal activity in humans who have been declared brain dead.
The proof-of-concept study which forms a part of the Reanima Project is the brainchild of two life sciences companies: Bioquark, Inc., based in the United States, and Revita Life Sciences, based in India.
Due to begin later this year, the trial will recruit 20 individuals who have suffered brain death as a result of traumatic brain injury , but whose bodies are biologically alive as a result of cardiopulmonary and trophic support a model referred to as a living cadaver.
To participate in the trial, each subject must be aged between 15 and 65 years, be unwilling for organ donation, and have written consent from a legally acceptable representative.
Researchers including Bioquark CEO Ira Pastor will test a variety of techniques that previous studies have demonstrated to possess neuroregenerative properties, and these will be combined with devices that have been shown to stimulate the central nervous system of coma patients.
What Happens After Coma And Vegetative State
When people start to regain consciousness, they may:
- follow simple instructions from others such as, Open your eyes, Squeeze my hand, Say your name, etc.
- communicate by speaking words or by indicating yes or no by head nods or gestures and/or
- use a common object in a normal way such as brushing hair with a brush, using a straw to drink, holding a phone to the ear, etc.
Persons with brain injury transition through the period of unconsciousness and subsequent stages of recovery at a slower or faster rate, largely depending on the severity of injury. Those with less severe injuries may transition through these stages more rapidly and some of the stages described here may be poorly recognized or not occur at all. Those with very severe injuries may stall at one or another stage and not be able to make the transition to a higher level of recovery.
For persons with more prolonged periods of unconsciousness, emergence from unconsciousness is a gradual process. Coma rarely lasts more than 4 weeks. Some patients move from coma to the vegetative state but others may move from coma to a period of partial consciousness. It would be very rare for a person to move directly from coma, or vegetative state, to a state of full consciousness.
Persons who have shorter periods of unconsciousness likely had less severe brain injuries initially. Consequently, they are likely to go on to make better recoveries than persons who had longer periods of unconsciousness.
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Patterns Of Recovery After Very Severe Brain Injury
Some individuals rapidly emerge from coma and briefly remain in the minimally conscious state before recovering a higher level of consciousness with mild impairments. Others may have a longer period in the minimally conscious state after emerging from the vegetative state and then usually have a greater degree of long-term impairment. Occasionally, persons remain in the vegetative or minimally conscious state for an extended period of time and, in rare cases, these conditions may be permanent.
How Do Coma Patients Wake Up
Someone who is in a coma is unconscious and has minimal brain activity. It is not possible to wake a coma patient using physical or auditory stimulation. Theyre alive, but cant be woken up and show no signs of being aware. The persons eyes will be closed and theyll appear to be unresponsive to their environment.
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Quick Answer: How Long Can A Brain Dead Person Live
Today, with ventilators, blood-pressure augmentation and hormones, the body of a brain-dead person could, in theory, be kept functioning for a long time, perhaps indefinitely, Greene-Chandos said.03-Jan-2014
When does a person die from brain death?
- In the United States and many other countries, a person is legally dead if he or she permanently loses all brain activity or all breathing and circulatory functions.
Shocking Number Of Patients Not Really Brain Dead
Studies from Canada indicate that approximately 20% of patients misdiagnosed as brain-dead are in fact conscious and have the potential to recover from traumatic brain injuries. This misdiagnosis can have fatal consequences that can result when physicians and loved ones pull the plug on life support systems that are keeping patients alive. New technology that detects brain activity could be the answer.
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How Long Can Someone Be Dead Before Being Revived
Blood circulation can be stopped in the entire body below the heart for at least 30 minutes, with injury to the spinal cord being a limiting factor. Detached limbs may be successfully reattached after 6 hours of no blood circulation at warm temperatures. Bone, tendon, and skin can survive as long as 8 to 12 hours.
Characteristics Of The Confusional State
- Severe impairment in attention, memory and other mental abilities
- Fluctuation in level of responsiveness
- 6. Excessive drowsiness and sleeping during the day
- Delusions or hallucinations
As with the vegetative and minimally conscious states, the rate and extent of recovery from the confused state vary from person to person. However, almost all people who reach the confused state go on to make further progress. The main factors that determine the eventual degree of recovery are the initial severity of the brain injury and some types of additional medical problems. The shorter the time the person is in the confused state, the better the eventual recovery will be. Mild medical complications such as sleep disturbance or urinary tract infection may prolong the confused state but do not necessarily influence the final outcome.
Once the confusional state resolves, people are usually much better able to pay attention, orient themselves to place and time, and retain memories for day to day experiences. Nevertheless, they are very likely to have some significant cognitive problems such as impaired memory or slowed thinking. These cognitive problems are likely to continue to improve as time passes. Some people make limited progress, while others make a good deal of progress.
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Things To Look For When Considering A Setting To Care For Your Loved One:
At various points in the process of recovery, persons in the minimally conscious or vegetative state may receive care in a wide range of settings. These include in-patient rehabilitation facilities, skilled nursing facilities, and long-term acute care facilities. The following are some considerations for selecting a place for care:
- Your family members current treatment team has had good experiences with the program when they have referred others there.
- The staff at the facility makes you feel comfortable, is accessible to talk with about your concerns, and answers your questions.
- The program and medical staff have experience working with the same kinds of problems that your family member has.
- The facility is informed about the specifics of the care your loved one needs and is able to meet these care needs. You can have a role in ensuring that a detailed nursing plan of care is developed.
- The program includes case management to assist in planning for the next level of service, whether it is transition to a rehabilitation program, a facility for long-term care, or home.
- The program provides education and training for future caregivers.
- The program uses specific procedures to measure progress.
If support services can be arranged, some persons in the minimally conscious or vegetative state can be cared for at home.
Why Is Gcs Important
Assessment of level of consciousness using the Glasgow Coma Scale is a tool requiring knowledge that is important in detecting early deterioration in a patients level of consciousness. Critical thinking used with the skill and knowledge in assessing the GCS is the foundation of all nursing practice.
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Theme Ii: Turbulent Confrontation With Successive Chains Of Stress
The process of caring for a brain dead patient is considered as continuously facing various stressors, such that they have to encounter all these factors and manage them in addition to the stress of caring for the patient. This theme is composed of the following categories:
3.2.1. Despair and disappointment after confirmation of brain death
This category consists of three subcategories and it states that after confirming brain death, nurses face a feeling of grief and they are greatly influenced by the feeling of frustration of the patients recovery and reassurance. A participant with eight years experience of working in the ICU and caring for brain dead patients stated, When, for definite brain death patients they say that the patient will not survive, and they will expire in a case of not donating their organs, you think about why they became brain dead. You become disappointed, because now, you are sure that they will not come back . A participant with thirteen years experience of working in the ICU and caring for brain-dead patients stated, For the work that you do for the patient and knowing that they will expire, your work seems fruitless, from this point of view, I said. Because they wont recover and you become disappointed that they wont come back .
3.2.2. Difficulty of declaring brain death to the family
3.2.3. Stressful experience of the first caring
3.2.4. Stress of being blamed by the family
3.2.5. Difficulty of confronting families feelings
Brain Death Is Legal Death
If someone’s brain dead, the damage is irreversible and, according to UK law, the person has died.
It can be confusing to be told someone has brain death, because their life support machine will keep their heart beating and their chest will still rise and fall with every breath from the ventilator.
But they will not ever regain consciousness or start breathing on their own again. They have already died.
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