Saturday, April 28, 2012

Permanent Vegetative State 2

Diagnosis
The vegetative state is diagnosed, according to its definition, as
being persistent at least for one month. Based upon class II
evidence and consensus that reflects a high degree of clinical
certainty, the following criteria is standard concerning PVS:
– PVS can be judged to be permanent, at 12 months after
traumatic brain injury in adults and children. Special
attention to signs of awareness should be devoted to
children during the first year after traumatic injury.
– PVS can be judged to be permanent if it lasts more than 3
months, in case of nontraumatic brain injury in both adults
and children.
– The chance for recovery, after these periods, is exceedingly
low and recovery is almost always to a severe disability.
Management
When a patient has been diagnosed as being in a PVS by a
physician skilled in neurological assessment and diagnosis,
physicians have the responsibility of discussing with the family
or surrogates the probability of the patient’s attaining the
various stages of recovery or remaining in a PVS:
– Patients in PVS should receive appropriate medical, nursing,
or home care to maintain their personal dignity and
hygiene.
– Physicians and the family/surrogates must determine
appropriate levels of treatment relative to the
administration or withdrawal of 1) medications and other
commonly ordered treatments; 2) supplemental oxygen and
use of antibiotics; 3) complex organ-sustaining treatments
such as dialysis; 4) administration of blood products; and 5)
artificial hydration and nutrition.
Recovery from PVS can be defined in terms of recovery of
consciousness and function. Recovery of consciousness can be
confirmed when a patient shows reliable signs of awareness of
30 | Critical Care in Neurology
self and their environment, reproducible voluntary behavioral
responses to visual and auditory stimuli, and interaction with
others. Recovery of function occurs when a patient becomes
mobile and is able to communicate, learn, and perform adaptive
skills and self care and participate in recreational or vocational
activities. Using these parameters, recovery of function can be
defined with the Glasgow Outcome Scale.
The life span of adults and children in a PVS proves to be
reduced; for most PVS patients, life expectancy ranges from 2 to
5 years and survival beyond 10 years is unusual. Once PVS is
considered permanent, a “Do not resuscitate (DNR)” order is
appropriate which includes no ventilatory or cardiopulmonary
resuscitation. The decision to implement a DNR order, however,
may be made earlier in the course of the patient’s illness if there
is an advanced directive or agreement by the appropriate
surrogate of the patient and the physicians responsible for the
care of the patient (Plum 2007).

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