Wednesday, February 3, 2010

Persistent Vegetative State: An apt description for the media coverage of PVS

The New England Journal of Medicine released a study today revealing some awareness in a minority of patients diagnosed with Persistent Vegetative State (PVS). Researchers used functional MRI tests on 54 patients with PVS or minimally conscious state (MCI). The MCI patient data is interesting but the meat of the study is in the 23 patients diagnosed as being in a persistent vegetative state, meaning that clinically all exams showed no signs of awareness. Four of these 23 patients showed brain activity in areas similar as healthy control subjects when given specific commands. One of these four patients was also able to respond to factual statements correctly by using a technique similar to answering yes-no questions.

My favorite part of the article is in the discussion section:
In the future, this approach could be used to address important clinical questions. For example, patients could be asked if they are feeling any pain, and this information could be useful in determining whether analgesic agents should be administered.
This would be the dawn of a new era where we have new tools to evaluate the symptoms of those who cannot verbally or physically communicate with us at the bedside. The caveat is the most patients with PVS in this study showed no signs of awareness and could not communicate in any significant manner even when placed in the fMRI machine.

Take a guess though what the media headlines focus on:
  • Scientists read the minds of the living dead (New Zealand Herald)
  • Patients in 'vegetative' state can think and communicate (The Telegraph)
  • Brain scan shows awareness in vegetative patients (BBC News)
  • Brains of vegetative patients show life (LA Times)
  • Study Finds Cognition in Vegetative Patients (Wall Street Journal)
These headlines are just wrong. They give the impression that all patients with PVS are aware and can communicate. In truth, this study showed that a minority of patients with PVS showed some signs of awareness, and those happened to only be in those who suffered from a traumatic brain injury (not from other causes such as anoxic brain injury). To be fair, there were some more appropriate headlines including Newsday with “Some vegetative brains show signs of awareness” and BusinessWeeks “Brain Scans Suggest Some Vegetative Patients May Be Aware”, but overall the media continues to show limited signs of self-awareness when reporting on journal articles.

Reference:
Monti, M., Vanhaudenhuyse, A., Coleman, M., Boly, M., Pickard, J., Tshibanda, L., Owen, A., & Laureys, S. (2010). Willful Modulation of Brain Activity in Disorders of Consciousness New England Journal of Medicine DOI: 10.1056/NEJMoa0905370

10 comments:

monitor said...

I still think that miracles can still happen. We don't know what the future holds. But we know who holds the future. Lets give these patients and their families some hope.

Eric Widera said...

I agree that hope is important. Patients and their families may hope for miracles, hope for cures, and hope for relief from suffering. What concerns me is not that patients, families, and health care providers hold out these hopes. What concerns me is the misuse or manupulation of hope to drive traffic to news outlets.

guym said...

The "just wrong" media headlines that Eric showed us are, in part at least, the result of the cocksure attitudes many of us in medicine have put forward to the families of patients in a 'vegetative state.' If you can find it, take a look at PVS expert Ronald Cranford's examination of Nancy Cruzan (a "Frontline" documentary) or his remarkable interview with Joe Scarborough about Terri Schiavo on MSNBC (at ). He may be 'right,' but he comes off as arrogant. And, when arrogance is shown to be wrong - even slightly - it promotes skepticism and the kinds of headlines we are now seeing.

-Guy

Alex Smith said...

The link to the disturbing MSNBC interview that Guy Micco mentions above can be found here.

Can I just say that "Scientists read the minds of the living dead" may be wrong, but it's soooo creative!

Eric Widera said...

Guy, I agree that physicians can often come across as arrogant in the media or even when talking to patients. This can lead to interest in sensational headlines around PVS. The problem though is that certain news outlets are bending over backwards to create sensationalism in this story. Take the very first line of coverage of this article by the NY Daily news.

"New research suggests that some patients thought to be brain-dead are able to communicate - and can even answer simple questions"

The NY Daily news (only one of many examples of this) has now included patients who are brain dead into the study protocol. The problem is that in no way does the NEJM article involve "brain-dead" patients. I can't help to think that they used the term "brain-dead" for a reason, and not just because of a complete lack of awareness of these conditions. I may be an arrogant doctor, but I'm not arrogant enough to think I can compete with the news media juggernauts that can twist a story into some grotesque form of its old self.

guym said...

Some writers for the popular 'news media' surely do look to sensational headlines to sell papers - though I don't know the full history of this, I suspect it's long, and yellow. But, physicians and others who 'should know better' are confused too! A wonderful study by by Stuart Youngner in 1989 of nearly 200 physicians and nurses "likely to be involved in organ procurement for transplantation" showed how little many of them understood about what they were supposed to know: 38% thought PVS patients were "dead." And, 32% said that, while they considered the brain-dead patient to be dead, they thought this because "no matter what was done the patient would die soon anyway" or because the quality of their life was unacceptable.
I do wonder what a study of this sort today would find. People, including medical professionals, are still confused about PVS and brain death. (Re the latter, note the President's Council on Bioethics' 2008 report "Controversies in the Determination of Death")

Eric Widera said...
This comment has been removed by the author.
Eric Widera said...

I completely agree that there is plenty of confusion among physicians – just see the GeriPal post on Sanjay Gupta’s book Cheating Death

A similar issue was brought up today in NPRs “On the Media”. They interviewed The Lancet's editor Richard Horton. He described how the publication of the deeply flawed autism/MMR vaccine study changed the way the journal with the new media.

Here is an excerpt:

“The lesson we learned is that anything that we publish will be picked up and used. It certainly made us much more risk averse, much more conservative”...” You cannot have a closed discussion the scientific community now-a-days”...“We used to think that we could publish speculative research which advanced interesting new ideas which may be wrong but which were important to provoke debate and discussion. We don’t think that now. We don’t seem to be able to do is have a rational conversation in the public space about difficult controversial issues without people drawing a conclusion which could be very very adverse.”

Drew Rosielle MD said...

I posted on this as well on Pallimed (here.)
Thanks for the media links. I can't bring myself to read them, as I only have a certain daily tolerance for intellectual laziness and malfeasance, which is usually exceeded by the morning news.

I think a key point in all of this is that it doesn't necessarily change the fundamental medical ethical analysis regarding medical decision-making for these patients. It *may* change it for individual families of course, but the question has never been, at its root, if these patients have any cortical activity or not. Instead it's whether or not they'd want their lives to be prolonged via invasive medical treatments in their current state and with their prognosis. Having a modicum of awareness may impact decision-making to be sure (for some families, although not in predictable ways), but it does not fundamentally change how these decisions should be approached.

I am also surprised no one has yet brought up the Captain Pike scenario of where this technology could lead for those few % of patients considered to be in PVS who have some awareness.

Anonymous said...

What a great resource!