PERSPECTIVE - New England Journal of Medicine - very good

[moobu2]

PERSPECTIVE
Terri Schiavo — A Tragedy Compounded
Timothy E. Quill, M.D.

The story of Terri Schiavo should be disturbing to
all of us. How can it be that medicine, ethics, law,
and family can work so poorly together in meeting
the needs of this woman who was left in a persistent
vegetative state after having a cardiac arrest?
Ms. Schiavo has been sustained by artificial
hydration and nutrition through a feeding tube
for 15 years, and her husband, Michael Schiavo, has
been locked in a very public legal struggle with
her parents and siblings about whether such treatment
should be continued or stopped. Distortion by
interest groups, media hyperbole, and manipulative
use of videotape have characterized this case and
demonstrate what can happen when a patient becomes
more a precedent-setting symbol than a
unique human being.
Let us begin with some medical facts. On February
25, 1990, Terri Schiavo had a cardiac arrest,
triggered by extreme hypokalemia brought on by an
eating disorder. As a result, severe hypoxic–ischemic
encephalopathy developed, and during the subsequent
months, she exhibited no evidence of higher
cortical function. Computed tomographic scans
of her brain eventually showed severe atrophy of
her cerebral hemispheres, and her electroencephalograms
have been flat, indicating no functional activity
of the cerebral cortex. Her neurologic examinations
have been indicative of a persistent vegetative
state, which includes periods of wakefulness alternating
with sleep, some reflexive responses to light
and noise, and some basic gag and swallowing responses,
but no signs of emotion, willful activity, or
cognition.

There is no evidence that Ms. Schiavo is
suffering, since the usual definition of this term requires
conscious awareness that is impossible in
the absence of cortical activity. There have been only
a few reported cases in which minimal cognitive and
motor functions were restored three months or
more after the diagnosis of a persistent vegetative
state due to hypoxic–ischemic encephalopathy; in
none of these cases was there the sort of objective
evidence of severe cortical damage that is present in
this case, nor was the period of disability so long.

Having viewed some of the highly edited videotaped
material of Terri Schiavo and having seen
other patients in a persistent vegetative state, I am
not surprised that family members and others unfamiliar
with this condition would interpret some
of her apparent alertness and movement as meaningful.
In 2002, the Florida trial court judge conducted
six days of evidentiary hearings on Ms.
Schiavo’s condition, including evaluations by four
neurologists, one radiologist, and her attending
physician. The two neurologists selected by Michael
Schiavo, a court-appointed “neutral” neurologist,
and Ms. Schiavo’s attending physician all agreed
that her condition met the criteria for a persistent
vegetative state. The neurologist and the radiologist
chosen by the patient’s parents and siblings,
the Schindler family, disagreed and suggested that
Ms. Schiavo’s condition might improve with unproven
therapies such as hyperbaric oxygen or vasodilators
— but had no objective data to support
their assertions. The trial court judge ruled that the
diagnosis of a persistent vegetative state met the legal
standard of “clear and convincing” evidence,
and this decision was reviewed and upheld by the
Florida Second District Court of Appeal. Subsequent
appeals to the Florida Supreme Court and the U.S.
Supreme Court were denied a hearing.

New England Journal of Medicine The article is PDF but a small file

[fryguy]

1. the wingers will never buy this

since it replaces religion and faith with medical and scientific reasoning - and the latter can never outweigh the former....

[Ilsa]

2. That's exactly true. They'll deny it until they need the medicine

and therapy and treatments. And PET scans will be some sort of God-directed voodoo magic, and they'll deny the scientific principles behind nuclear medicine, and they won't miss their medicine. They'll have bake sales, (BBQ's are popular down south) and fundraisers to get it if they aren't covered by insurance. And when it actually cures them, they'll claim it is because Reverend Televangelist was praying for them.

[trudyco]

3. NEJM - bunch of losers

I'm sorry but if the family wanted to try HBOT (Hyperbaric Oxygen) and vasodilator - premier alternative medicine for brain injury that western medicine like NEJM can't see past because it isn't cutting you up or giving you a pill... so she never got it. They always claim its "unproven". Yeah, like Viox was proven to be safe. Well, BFD. They've paid for her vegetative state for 15 years. Why couldn't they cough up the money to see if it worked?

There is also estim or something like that where they can improve swallowing. She may be too far gone, but we'll never know unless they try these alternatives like HBOT.

[LastDemocratInSC]

4. Facts remain facts while opinions come and go

The lady has no cerebral cortex. That's a fact. No improvement in her condition is possible by using hyperbaric oxygen treatment. That's a fact. People want to use her now like a crash-test dummy. That's a fact.

[arikara]

8. But I have not seen it mentioned on any of the MSM

that her cerebral cortex is gone and has been replaced by cerebral spinal fluid. All the MSM shows over and over and over are those few seconds of the video where it appears that she is responding to her mother. They don't show the clips apparently on the same video where she isn't responding to anything.

Has anyone seen any reporting where anybody explains to the masses exactly what the cerebral cortex does, and what happens if it is gone? I've seen a lot of irresponsible reporting over the past few years but this is the worst.

Although I disagree with them, I do feel terrible for the parents. I have some inkling of what they are going through. When my daughter was a young teen she was in a coma for several weeks from a head injury. I remember sitting by her bed at one point thinking that even if she never woke up I didn't want her to die. However I know that had she not woke up and if her brain was effectively dead I would not have wanted to force her to stay alive, it would be just too cruel.

I hate this frenzy over this poor unfortunate woman, how can these fundy's live with themselves?

[ender]

5. go pound sand.

the new england journal of medicine is the premier medical hournal in the united states.

who are you to question its veracity?

[trudyco]

18. Who am I ? An informed American citizen with half a brain....

I don't trust what someone says just because I've been told they are an expert. We've been fed that pap for years now. All news has to bring in an "expert" to discuss something. Like us plain joes can't just figure it out and talk about it ourselves. You aren't allowed to have an opinion if you aren't an "expert".

When it comes to medical doctors they have their biases and opinions, they just mask them as facts. Because they are "experts" people just blindly believe them. If they get into NEJM why they must know everything, right? Bah.

I've had a child with a brain injury and know parents with brain injured children. I've seen the ones that listen to their doctor (you know, the "expert") and do the standard PT/OT/ST. Then I see the ones that risk being ridiculed and try "alternative" medicine. Guess which ones get results? HBOT. Nutrition. Alternative medicine. Alternative therapy. But they don't get peer reviewed studies because no one company or person makes money off of it, so who's going to cough up the money to pay for the studies? One HBOT study in Canada was purposely distorted... anyways I could go on and on but I won't. This has been our family's personal experience, too. I got suckered into the traditional routine the first few years, then finally went out on a limb. And was shocked that the so called experts didn't know shit when it came to brain injury.

So anyways the family should have tried HBOT a long time ago (Tomatis, too). Don't know how much it could help considering the severity but it is NOT quackery to suggest this. OTOH I mistook vasodilators for cuffing. Never researched it so have no opinion. It is rather silly to quote that it may do more harm than good in this case, though, eh? Our understanding of the brain keeps evolving. There is no such thing as fact, just current theory. Or opinion.

Now I better go find some sand to pound. If only I knew what that meant. Know any experts *wink*

[sandnsea]

10. The judge did look at it

He looked at it objectively. The problem was that the doctor who was touting the HBOT had NO case studies to say it worked on anyone in Terri's condition. He didn't present anything to support his claims that these therapies would work for her.

"He (Hammesfahr) admitted that vasodilation therapy and hyberbaric therapy were intended to increaseblood and oxygen supply to damaged brain tissue to facilitate repair of such tissue. These therapies cannot replace dead tissue."

[trudyco]

19. The expert on HBOT is Neubaur - sp? and he lives in Florida

He is THE person to talk to about HBOT for brain injury. Personally, I think the judge should have allowed the 6-8k for the initial 40 session therapy and do another scan to see if it made any difference. How much money have they spent on her already? As for proof beforehand, its not like there are a lot of cases out there to compare with. Almost all brain injury HBOT has to be private pay and its a lot for a family already taking care of the brain injured. Most families can't afford it.

If the Repubs are so into getting into this family's private affairs then maybe they'd pay for the HBOT. A lot of families with brain injured loved ones would be interested to see if it did anything. If it was paid for I really don't see why the judge needs to step in and stop it.

[BrklynLiberal]

12. None of that will work when the cerebral cortex has turned to mush.

All the brain scans show that her cerebral cortex has withered and been replaced by spinal fluid. There is no upper brain there. All that is left is the brain stem that controls such basic life support reflexes such as breathing.
There was a medical expert on today that said these feeding tubes were orignally designed for very short term use. For patients who were going thru some temporary or short disability that necessitated tube nourishment thru the abdomen. They were never intended to be used by someone for 15 years or more.

[trudyco]

20. But lots of CP and other disabled kids have gtubes

for their whole lives. Sounds like she has a tube down her throat. For 15 years! Why not a g-tube? This case is just so bizarre.

If the repubs are willing to pay for alternative therapies like HBOT and vasodilators I say let 'em. They may not do enough for this poor soul, considering her condition. But it may put a spotlight on these therapies and who knows may show some improvement.

[Mojorabbit]

15. Her

brain has flatlined on EEG for fifteen years. Nothing will bring her back. Truly.

[roseBudd]

17. The quack that claims hyperbaric treatment and vasodilators will help...

has no research to back up his statements. He was suspended and put on probation by in 2003 by the Florida Board of Medicine:

http://www.doh.state.fl.us/mqa/FinalOrders/03-17-03/DOH-03-0182.pdf

His Nobel prize nomination is phony since it was from a FL congressperson and hence not eligible.

In addition his claims for vasodilator therapy for stroke victimshave merited a mention on QuackWatch:
http://www.quackwatch.org/01QuackeryRelatedTopics/Tests/tcd.html

"The theoretical basis for Hammesfahr's vasodilation treatment for stroke clashes with current knowledge about stroke physiology. In fact, the prevailing current belief is that such treatments should worsen stroke outcome, not improve it. I believe that vasodilation treatment for stroke patients should be done only as part of an approved peer-reviewed protocol that includes informed consent about the treatment's experimental status and possible risks. Because of the potential risk, I doubt that an institutional review board would permit such a study unless animal studies can demonstrate that the treatment is safe and potentially useful."

Schiavo experienced 11 minutes of hypoxia. She was only intubated because the husband insisted. Her cerebral cortex is gone, she has no brain activity. The Schindlers are being cruely manipulated by hucksters. Hammesfahr has done no research. None. Ever. There are no rats who have magically regained brain activity or regrown a cerebral cortex from any treatment

[trudyco]

21. Quackwatch is a bunch of docs immersed in western medicine

masking their opinions and bias as "expert" facts. The claim to use HBOT for head injury would be experimental and you shouldn't have to pay for it - huh?

This is so controversial a set of doctors and parents have formed their own group to counteract the Hyperbaric and Undersea group. Some parents have sued their state to consider it covered for brain injury with medicaid because this so called experimental treatment was shown - using brain scans before and after- to significantly improve brain function. (Now this was with children and I'm sure they were in better shape that Ms. Shiavo.)

Just look around, a lot of other people are tentatively trying these so called quack therapies and getting results. Thats why alternative medicine is growing.

Here's another example. For over 30 years ophthamalogists (MDs) have claimed vision therapy (usually done by optricians - not MD) doesn't work. Its quackery. Today many ophthamalogists tell their patients its surgery to cut the muscle to the eye or patching or live with it. Thats all the choices. Hey, they are the experts. They are MDs. But a few years ago the ophthamalogists started a subspecialty called orthoptics. Guess what. Its a subset of vision therapy.
Well I guess now that they are making money on it, it isn't quackery.

So anyways, the messenger sounds like a quack but the message isn't. Actually the messenger sounds like he can be bought - he was reprimanded for monetary reasons, right? Not technical quackery.

[patcox2]

25. By "Western medicine" I assume you mean "based on science?"

Just asking, what with all the incredible new advances in medicine being made by witch-doctors and shaman lately, you are probably right, we should all abandon "western (said with a sneer) medicine." While we are at it we can abandon so called "western science." Look at how they eradicated polio with accupuncture, after all, and how they eliminated smallpox with holistic medicine, hell, now that cancer is completely curable by simply going on a macrobiotic diet, who would want to go back to that stupid old "western medicine."

[roseBudd]

27. Hyperbaric oxygen therapy for the adjunctive treatment of traumatic brain

Terri Schiavo suffered from hypoxic–ischemic encephalopy NOT a traumatic brain injury. Whether HBOT may have helped in 1990 is moot question at this point. The dead parts of her brain are now gone and replaced with spinal fluid.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15495120

Bennett MH, Trytko B, Jonker B.

Diving and Hyperbaric Medicine, Prince of Wales Hospital, Barker St., Randwick, 2031, NSW, Australia. [e-mail]

BACKGROUND: Traumatic brain injury is common and presents a health problem with significant effect on quality of life. Hyperbaric oxygen therapy (HBOT) has been suggested to improve oxygen supply to the injured brain and, therefore, to reduce the volume of brain that will ultimately perish. It is postulated that the addition of HBOT to the standard intensive care regimen may result in a reduction in patient death and disability as a result of these additional brain-preserving effects. OBJECTIVES: To assess the benefits and harms of adjunctive HBOT for treating traumatic brain injury. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library Issue 4, 2003), MEDLINE (1966 - 2003), EMBASE (1974 - 2003), CINAHL (1982 - 2003), DORCTHIM (1996 - 2003), and reference lists of articles. Relevant journals were handsearched and researchers in the field were contacted. SELECTION CRITERIA: Randomised studies comparing the effect on traumatic brain injury of therapeutic regimens which include HBOT with those that exclude HBOT (with or without sham therapy). DATA COLLECTION AND ANALYSIS: Three reviewers independently evaluated the quality of the relevant trials using the validated Oxford-Scale (Jadad 1996) and extracted the data from the included trials. MAIN RESULTS: Four trials contributed to this review (382 patients, 199 receiving HBOT and 183 control). There was a trend towards, but no significant increase in, the chance of a favourable outcome when defined as full recovery, Glasgow outcome score 1 or 2, or return to normal activities of daily living (relative risk for good outcome with HBOT 1.94, 95% confidence interval 0.92 to 4.08, P=0.08). Pooled data from the three trials with 327 patients that reported mortality, showed a significant reduction in the risk of dying when HBOT was added to the treatment regimen (RR 0.69, 95% CI 0.54 to 0.88, P=0.003). Heterogeneity between studies was low (I(2) =0%), and sensitivity analysis for the allocation of dropouts did not affect that result. This analysis suggests we would have to treat seven patients to avoid one extra death (number needed to treat 7, 95% CI 4 to 22). One trial suggested intracranial pressure was favourably lower in those patients receiving HBOT in whom myringotomies had been performed (WMD with myringotomy -8.2 mmHg, 95% CI -14.7 mmHg to -1.7 mmHg, P=0.01), while in two trials there was a reported incidence of 13% for significant pulmonary impairment in the group receiving HBOT versus 0% in the non-HBOT group (P=0.007). REVIEWERS' CONCLUSIONS: In people with traumatic brain injury, the addition of HBOT significantly reduced the risk of death but not of favourable clinical outcome. The routine application of HBOT to these patients cannot be justified from this review. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously, and an appropriately powered trial of high methodological rigour is justified to define those patients (if any) who can be expected to derive most benefit from HBOT.

[Emillereid]

26. I am as open to alternative therapies as anyone can be -- but I

don't see how in world HBOT or vasodilation can restore function to an absent cerebrum. Her cerebral hemispheres atrophied and the cavity is filled with spinal fluid. This is a whole lot more than 'brain damage.' This is a case of missing brain! This poor woman has been dead for 15 years -- all that remains is her reflexive body.

[Harlequin]

6. Regrettably, as discussed on the NASA topic, we know what Team Bush

thinks of Scientists: expendable.

[nothingshocksmeanymore]

7. Dr Quill hits the nail on the head

If she could wake up for 15 minutes and be asked what she wanted knowing she has to return to that state, what would she want.

[Nothing Without Hope]

9. This is all just a test case for attacking judicial authority over

reproductive rights -- that's why the legal fees are being paid by pro-lifer activists -- and, if that works and all abortion is outlawed, why then they'll just attack any judcial ruling on any subject whatsoever if it seems inconvenient to them and their endlessly greedy cronies.

I think they don't realize how repugnant their acts are to most Americans because they have no clue about a sense of right and wrong themselves. They are totally amoral monsters, as they just keep proving over and over again with each fresh new outrage.

[Bozita]

11. We live in a time of growing religious extremism

Could someone please explain to me the differences between the Taliban and the American Christian nutcase creationists?

I realize that "nutcase" and "creationist" are redundant.

It just makes no sense.

[alittlelark]

13. Sorry, they're Scientists and Doctors... they are EVIL

Why should the R-W whackos trust them? They believe in FACTS....oh, the horror !!!!

[dutchdoctor]

14. That is a great article, Kicking and recommending for greatest! n/t

[Danmel]

16. That's from Mass-a CHU-sets, isn't it?

That's not America anyway. I know that because George W told me so.

[DearAbby]

22. Seems like everyone is overlooking...Terri did not wish to have experiment

experimental procedures done on her, she did not wish to be kept alive by these means for the last 15yrs. The courts have determined this.

I can not see how this treatment can regenerate 70% of Brain mass that is now liquefied.

[90-percent]

23. A&E thursday night

The prolific Bill Curtis did a show on this last night. He found a neurologist that specialized in bringing comatose people back to life, talking and responding and all that. He stated he could do the same to Terry.

WTF is up with that????

brain dead is brain dead, right?

Is there really any debate about Terry coming out of pure vegatative state? The show implied some scientific types felt there was a chance, with proper therapy?

I'm confused. My family lost my sisters husband like this in 1992. He had a heart attack and was revived much later - body survived, but his soul and brain didn't. God, did that ever suck. Doc advised pulling the plug pretty early on.

-85%

[Boo Boo]

24. Terri is not comatose

She's as conscious as she's ever going to get.