Are coma patients written off too easily?

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Last month’s skiing accident, which left Queen Beatrix’ second son, Prince Friso, in a coma, has sparked debate in the Netherlands about the treatment of comatose patients.

Every year, between 1,000 and 3,000 Dutch people end up in a coma. The majority regain consciousness within a few days and 18 percent die. But what happens to those who open their eyes but don’t come round? Developmental psychologist and clinical neuropsychologist Henk Eilander says it’s often a question of wait and see:

"The policy in this country is to wait until someone regains consciousness by themselves. Of course, they get treatment – for instance, if their blood results aren’t good. A physiotherapist will also manipulate their limbs if there’s muscle tension. No treatment is administered, though, to bring them back to consciousness."

It’s accepted that coma patients should be able to breathe for themselves within a week to ten days. The brainstem should be functioning enough to produce the signals which cause respiration to take place. If that’s not the case, Dutch policy is to treat the case as medically hopeless and doctors are then allowed to terminate treatment.

If the unconscious patient is breathing independently, clinicians will wait to see if there’s a possibility that the patient will come round or be able to respond.

"All over the world, a distinction is made between people who have lost consciousness following an accident or a blow to the head and those who suffered a lack of oxygen. In the case of oxygen deprivation, they have to have displayed a return to consciousness within three months. They must exhibit some reaction to their environment. For people with other brain injuries, this limit is set at one year."

The longer a person has been in a coma, the greater the chance is that they will die. If the patient opens their eyes but remains otherwise unresponsive, they are considered to be in a vegetative state. Of course, some people make a partial recovery. The display of emotions or looking at things is a sign that consciousness is returning; this is considered to be a minimally conscious state.

It’s not always clear whether a patient is minimally conscious or in a totally vegetative state and hospitals don't have time to wait for an outcome. After three to six months, relatives are usually advised to move the patient to a nursing home.

Often, once a patient is in a home, no more tests of their faculties are done. Since no one is able to say what quality of life they have, the decision may be taken to terminate medical treatment and/or stop feeding. In the end, it's up to the family to decide, but Dr Eilander says it's never quick, and certainly not easy.

He still believes, though, that much more should be done for coma patients. Research has shown that targeted treatment gives people under 25, including children, twice the average chance of regaining consciousness. Thus people up to age 25 in a vegetative state are treated, while those over 25 are not.

Dr Eilander, who pioneered this treatment for young people, suspects the cut-off point was purely down to financial considerations:  

“When adults were admitted to our rehabilitation centre, they weren’t allowed treatment; it’s more costly than a nursing home. When we showed that treatment was effective for people up to the age of 25, we were told we hadn’t done research on people over 25, so we weren’t given permission to treat older people. That is, of course, bizarre circular reasoning.”

Dr Eilander is sure that people who appear in a vegetative state can still lead meaningful lives.

“I’m convinced that targeted treatment and activating their brains is good for them – that their brains can then function better. There’s been lots of research to prove this, not on these patients, but on people with brain injuries. This has to mean that the targeted treatment of people in a vegetative state is better than doing nothing.”

Dr Eilander compares it to a baby who has to be taught how to walk and talk: "If you do nothing, the baby will scarcely develop.” He also thinks treatment should start as soon as possible. The sooner this happens, the less chance that the brain will make 'faulty connections' which could lead to major cognitive or behavioural problems in the long term. That’s why he finds it so distressing that no targeted treatment is on offer in the Netherlands for people over 25 who are in a vegetative state.

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