Plugging One’s Life: A Study of Brain-injured Patients

When are you considered alive? Life is determined by the capability for self-sustenance of biological processes, and the ability to maintain homeostasis and respond to the environment. However, our lives are much more than simply being a biological organism. Whether it boils down to our experiences, relationships, or possessions, consciousness is what allows us to appreciate these aspects of life. However, imagine a scenario where a family member of yours suddenly lost consciousness for an extended period of time, being hospitalized and placed on life support during that time. If you were faced with a decision to continue or terminate this life support, what would you choose? Would your answer change if you knew that life support costs around $10,000 per day, the patient may have cognitive dysfunction after treatment, or that further complications can occur, causing more pain to the patient before death? This is the decision that families of brain-injured patients have to make, and it has long been a controversial issue with varying perspectives on it.

Brain-injured patients who experience loss of consciousness are diagnosed with one of the three disorders of consciousness (DoCs): comas, persistent vegetative state, and minimally conscious state. A coma occurs when a patient is unable to respond to any amount of external stimulation—such as conversation or light—due to depressed brain activity. Symptoms of a coma include irregularities in breathing, no response to physical stimulation except reflexes, and unusual posture, which generally lasts for a few weeks. A vegetative state is similar to a coma in that it is a state of unconsciousness in which a patient lacks cognitive function. However, patients in this state can have basic responses to their environment, such as blinking in response to a loud noise. Vegetative states lasting more than one month are classified as persistent vegetative states, a rare condition in which the chances of recovery dim over time. Finally, a minimally conscious state is when a patient shows a minimal awareness of their environment. Periods of communication or response in these patients can be observed, but they generally have the same prognosis as those in a vegetative state. Treatment for DoCs resembles life support: an artificial feeding tube for nutrition, a catheter to remove bladder waste, a ventilator for airflow, and constant movement of the body to avoid pressure sores, damaged skin and tissue caused by lack of blood flow. 

A patient is removed from life support if they are declared to be brain-dead (a legal form of death), due to an absence of brain activity and the inability to breathe without a ventilator. DoCs are not necessarily classified as brain death, but symptoms may greatly resemble that of a brain-dead patient, and removal of life support can be considered by the patient’s caretakers. It is commonplace for a doctor to have a thorough discussion with family members of a DoC-inflicted patient about their prognosis and continuance of life support within 72 hours of the patient’s admission. Three main factors are considered when making such a heavy decision: futility in treatment, the patient’s preference, and relations. Futility in treatment examines the success rate of the treatments and implores patients to stop life support if the treatment’s odds of success are significantly low. If a patient has marked their preference as “do not intubate” (DNI), life support should not be administered in compliance with the request to not be put under a ventilator. Finally, priority is given to certain relations of the patient to determine future treatment and life support, typically starting with the patient’s spouse, then any adult children, then parents, and then other family members. It has been found that communication with the doctor is a high priority for families of these patients, and enables a clear path of treatment.

However, policies for withdrawing life support often spark controversy. Although DoC-afflicted patients may display vital signs, their lack of consciousness questions the notion of life. Many believe that life is meaningless without consciousness, and many scholars have proposed to consider the vegetative state as a legal death. Others believe patients have the fundamental right to live, and insist life support must be provided either way. The patient’s cultural values can play a key role in this decision, as collectivistic cultures that focus on community, rather than individualistic cultures such as the U.S., may have different perceptions of death. Futility in treatment is also commonly argued over, as there isn’t a clear definition for what makes a treatment “futile.” Most importantly, it is difficult to determine the patient’s wishes for recovery if they do not have a DNI; placing the decision to withdraw life support in their relatives’ hands is subject to biases and ethical concerns about the value of life. 

Arguments supporting and refuting the continuation of life support each have their logical foundations, and it is important to analyze their moral and legal implications. The most common argument for continuing life support would be that the patient is technically alive, as they have basic reflexes and biological functions. However, opponents will be quick to point out that many patients do not recover full cognitive or physical function and question the meaningfulness of that life to the patients. Futility in treatment often sparks arguments on both sides, as it is often difficult to pinpoint what statistical possibility would constitute a “futile treatment.” Medical costs and resources are also considered; mechanical ventilation, feeding tubes, medical personnel, and testing can cost over $10,000 a day, which may not be financially stable for families. These are just a few factors that doctors and families may consider before making a decision; however, it is still required by law that life support is administered to patients if requested by family members, regardless of a doctor’s medical advice.

A recent study posted in the Journal of Neurotrauma on May 13 examined the recovery potential of patients with traumatic brain injuries (TBI). The study utilized a database containing over 1,000 TBI patients and chose to compare 80 patients who had died from withdrawal of life support to another 80 patients whose life support was continued. Although the majority of patients on life support ended up dying in the hospital, 42 percent of those patients managed to recover within the next year to develop a degree of independence. These results question the decision of doctors to withdraw life support within the first 72 hours of patient admission. According to professor Dr. Claude Hemphill of the University of California, San Francisco, “These people look very sick when they come in. As a consequence, many physicians felt compelled to make a decision early.” However, this does not overlook the fact that doctors still have to consider the type of life that the patient wants to live, whether it’s one with a disability or none at all. 

The decision to determine the continuance of life support is a heavy one for both doctors and families. There is no right decision to make; it is solely dependent on what the patient wants. However, it is agreed upon that these decisions require more time; there should be more time given to analyze the patient’s situation and to allow the families to determine what the patient wants. Underlying this process should lie a basis of respect and understanding for whatever decision is finalized, as the ultimate goal is to provide the patient comfort until recovery or death.