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Byline: Linda Carroll Medical Tribune News Service

As life-prolonging technology improves, society is being forced to confront a very basic question: When, exactly, does life end?

While there is almost universal agreement that complete loss of brain function is equivalent to death, a debate rages among doctors - and the general public alike - when it comes to patients in the persistent vegetative state (PVS).

Some argue that the definition of death should be changed from a whole-brain criterion to a higher-brain criterion. Under the latter, patients in a persistent vegetative state would be classified as dead.

A recent survey of neurologists and nursing-home medical directors published in the July 15 issue of the Annals of Internal Medicine found that the vast majority - over 90 percent - believed that these patients would be better off dead.

A smaller proportion, 54 percent of medical directors and 44 percent of neurologists, said that patients in the persistent vegetative state should be considered dead, the survey showed.

All this alarms Dr. Kenneth Prager, an associate professor of medicine and chair of the medical ethics committee at the Columbia-Presbyterian Medical Center in New York. ``It's a very slippery slope,'' he said. ``Who is to say that the definition of death might not then be stretched to someone who is conscious, but is blind and unable to talk?''

Even if a doctor agrees that PVS is equivalent to death, he has to be very sure of his diagnosis, Prager pointed out.

A study published in the July issue of the British Medical Journal highlights the difficulties in arriving at an accurate diagnosis, he added.

The study looked at the medical records of 40 patients admitted over a three-year period to a unit specializing in rehabilitating patients with chronic brain damage.

More than 40 percent of the patients had been misdiagnosed as vegetative, the study found. All these people were eventually able to communicate with doctors either through eye pointing or through a sensitive touch buzzer system, it showed.

The survey in the Annals of Internal Medicine found strong consistency when doctors were questioned about rationing treatment for PVS patients. More than 90 percent said they believed it was ethical to withhold or withdraw cardiopulmonary resuscitation, dialysis, antibiotic therapy or transfusions. Most would not screen for cancer or high blood pressure.

Nevertheless, ethicists say, it's not up to the doctor to determine how much care a patient should receive.

Physicians may feel they know better than others how limited life in PVS is, but ``ultimately, it's a value judgment,'' said Dr. Peter Terry, a professor of medicine in the division of pulmonary and critical-care medicine and a member of the Johns Hopkins Bioethics Institute in Baltimore.

``When it comes to putting a value on that form of life, the man on the street is just as qualified as the physician,'' he said.

The doctor can advise family members and other surrogates about the futility of therapies, but should still offer the treatments, according to Terry.

The best approach is to discuss future treatment options with surrogates as soon as a diagnosis of PVS is reached, said Dr. Ronald Cranford, a neurologist and medical ethicist at Hennepin County Medical Center in Minneapolis.

``What I do is sit down with the family,'' he said. ``We talk about all the possibilities. I say, `These are some of the things that could occur. This is what we can do. How do you want us to respond?' ''

Once family members understand that a patient can be unconscious with his eyes open, they generally agree not to treat aggressively, according to Cranford.

However, some families never accept the diagnosis of PVS. ``Then you have a substantial ethical dilemma,'' Cranford said. ``On the one hand, you're being asked to provide futile treatment. And on the other hand, as a general rule, we defer to families. Do we override the family? So far, the courts have said, `No.' ''
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Article Details
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Title Annotation:L.A. LIFE
Publication:Daily News (Los Angeles, CA)
Date:Jul 29, 1996

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