Sometimes, after a brain injury, patients have periods of being awake but unable to speak with those around them. Are they still experiencing pain, pleasure or discomfort? Could or not it's that they understand when family members speak to them, even when they can't answer? Doctors and families alike find themselves asking these questions, unable to reply them with any confidence.
Despite the shortage of certainty, doctors are still expected to diagnose. They follow established procedures, searching for signs of “purposeful behavior” At the bedside, if a patient can follow commands or interact along with his environment in apparently purposeful ways (for instance, squeezing the doctor's hand or following an object along with his eyes), he is claimed to be “less are less conscious than”.
Some patients, in contrast, show no purposeful behavior during wakefulness. Traditionally, the term “vegetative state” has been applied to those patients, although the term has been Criticized as inhumane.. Rather increasingly, “unresponsive wakefulness syndrome” is used.
These patients should not completely unaffected. They sometimes moan, cry or yawn, but these movements are frequently seen by their doctors as mindless reflexes. For an extended time, it was believed that these patients simply couldn't have a conscious experience.
Over the past 20 years, researchers have found that this assumption is commonly mistaken. One problem is that bedside diagnostics are unreliable. Distinguishing purposeful behavior from anxiety just isn't easy, and standard clinical examinations may miss subtle signs of peripheral awareness. 40% of cases.
Recent studies have also suggested that up to 25% Apparently unresponsive patients try to reply. Evidence comes from measures of brain activity. For example, when asked to clench their right fist, the patient's hand won't move, but their brain activity will show a response, suggesting an try and clench their fist. . These patients can hear and understand commands thoroughly, a condition referred to as “covert consciousness.”
Even patients who cannot follow commands in this manner often show brain activity in networks related to consciousness. For example, More than a third Patients have activity within the cerebral cortex: the outer layer of the brain liable for functions resembling pondering, planning and processing complex information. This suggests that the parts of their brain involved in consciousness are still functioning.
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Yet researchers disagree on whether the cerebral cortex is required for conscious experience. Some evidence suggests that Mid braina component of the upper brain, could also be sufficient to support a state of “primary consciousness” that features basic sensations resembling fear and pain.
Some midbrain activity should remain in all patients who cycle between sleep and wakefulness since the midbrain regulates these cycles. Therefore, even when neither behavioral tests nor measurements of brain activity reveal any sign of consciousness, we should not ready to rule out the potential for continuing the experiment.
Precautionary attitude
So we'd like to take one. Precautionary attitude towards these patients. Rather than drawing sharp lines between conscious and unconscious patients, we'd like to take seriously the chance that each one conscious patients could also be able to some type of experience, including pain and pleasure.
Taking this possibility seriously doesn't mean to discount the extent of brain injury, nor does it mean to assume that patients will at some point regain the flexibility to speak. Sometimes it doesn't. Doctors should differentiate the diagnosis. Assessment And be honest with relatives in cases where the prognosis is bleak. But they need to never assume that have is absent.
Physicians' guidelines for the diagnosis of “disorders of consciousness” (the medical term for reduced or absent signs of conscious behavior) should reflect this need for caution. gave European guidelines suggests that physicians shouldn't only search for signs of purposeful behavior but in addition assess patients' mental activity at any time when possible. Although it is a step in the correct direction, current methods focus totally on the cortex and ignore the potential for conscious experience without cortical activity.
gave UK guidelines Add more general precautionary recommendations. They emphasize that each one patients with impaired consciousness needs to be treated appropriately for symptoms of pain or discomfort. But guidelines should go further. At the very least, doctors must tell patients what is occurring to them and why, in the event that they can listen and understand.
More fundamentally, though, doctors shouldn't be expected to attract sharp lines between “minimally conscious” and “vegetative state” patients. We should not confident enough to make this call. Instead, we must always use the broader term “prolonged impairment of consciousness” and tailor care to every patient's needs. More detailed classification systems Drawing on the newest scientific evidence.