Brief Answer:
Permanent vegetative state considered irreversible

Detailed Answer:
Good morning. My name is Dr. Dariush Saghafi and I am a Neurologist from the XXXXXXX Ohio region of the world. Greetings to wherever you are writing from and please accept my sincere apologies for your family member being diagnosed as you state, "permanent vegetative state."

I would say that in all probability your family member has been seen (and is perhaps still followed) by a neurologist. That would be the medical specialist most qualified and most sought after by other doctors to make this kind of diagnosis on a critically or chronically ill patient.

If this is the case then, the term itself tells us the irreversibility of the situation. In other words, the neurologist has performed a series of tests on the patients (meaning physical as well as possibly other diagnostic tests) and determined that the brain function is in a state of alertness which unfortunately cannot be expected to reverse itself to any higher level of consciousness or awareness than where it is at this point. Therefore, if your relative is bedridden, unable to speak, unable to move, and apparently not interacting with the world around him needing essentially all support measures (except for a respiratory) that in fact, that is all the better that you can expect to see him. This is because of damage to the brain centers which allow us to "wake up" and be the people who normally are when not in such a low level of brain function.

You are correct in stating that he is not in coma nor is he considered brain dead because in fact that is considered to be a different variation of this theme altogether.

Answering the question of how likely it is for the physician to be wrong cannot be done with a single number. But I will say it this way.....with every passing day that your relative remains as they were when they first entered this state the percentage probability that the physician is correct in the diagnosis of PERMANENCY INCREASES and gets closer to 100. That makes sense doesn't it?

I've had numerous patients in these types of states without 24hr. rotating shifts of nurses. Every person is different in terms of their longevity and it is more contingent upon their other medical conditions as to how likely they are to survive longer or shorter.

So, if your family member also has diabetes, heart disease, history of strokes, and problems with blood borne infections (you mentioned pseudomonas) then, the chances of surviving for an extended period of time beyond the 3 years they've already survived would probably be worse compared to a 20 year old in the same vegetative state but who has nothing wrong them at all....except for whatever the reason that they fell into such a state. Make sense?

There simply are no numbers to give to you in this type of situation....not in terms of the likelihood that the MD is wrong about the diagnosis (which neither you nor I really believe to be the case as things stand, right?) nor about how long they are destined to last. I've been surprised by my patients in this sort of state in both directions. I've had patients go for YEARS beyond my expectations and others who shocked me when I was called in the middle of the night to be told that their heart had stopped....after I thought "heck if anything ever goes it will NEVER BE THEIR HEART!" Little did I suspect that would be exactly what would fail.

You just never know.

I wish you and your family every bit of hope possible in this difficult time and that the final outcome (whatever that may be) is in your relative's best interests and wishes for a happy and peacefully fulfilled life.

If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING to the answer?

Also, if you have no further questions or comments to place could you also do me the favor of CLOSING THE QUERY which will alert the network to process, archive, and credit this question appropriately for future reference.

In the future I'm happy to answer questions directed to may attention simply by using the following website:

http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474

This query required 35 minutes of physician specific review, research, and final draft documentation for envoy.

---

Brief Answer:
Medicolegal questions

Detailed Answer:
Good morning once again from XXXXXXX Ohio, USA. Thank you for your updated response and complimentary comments. I am hopeful the family will be able to work through this difficult situation and I will try answering your EXCELLENT questions but with the caveat that the medico-legal layer of medicine is outside my area of expertise. Add to that the fact that I am pulling up a location of the Philippines as to where the consult is originating and so what I say only applies to the laws as I understand them in the United States. But let's give it a whirl and see what you think. I will respond paragraph by paragraph to your points of import if that's OK with you so hopefully I won't miss anything.
======================================================
PARAGRAPH 1

Thank you for your very comprehensive response Dr. Saghafi. I value your medical opinion. In line with what I have shared with you and in relation to your opinion that a permanent vegetative state is almost 100% indeed permanent based on the medical history of the patient, what is the correct approach that the family can do when it comes to crucial decisions that have to be made in the event that a life or death type of emergency arises such as cardiac arrest or dangerously low blood pressure and the like?

RESPONSE: In the US the correct approach for families to follow in situations where a loved one is now classified as incompetent and incapacitated to make medical decisions for themselves we appeal to a LIVING WILL which the patient may have filed prior to their becoming incapacitated. Such a document can then, be utilized by whomever the family shall designate as the sole LEGAL DURABLE POWER OF ATTORNEY (memorialized by an attorney on special paperwork) in order to make decisions for the patient in a manner consistent with the Living Will which specifies what is to be done medically in the case of cardiac arrest or dangerously low blood pressure etc. In the absence of a Living Will, a DURABLE POWER OF ATTORNEY may still elected by the family and that person should then, exercise medical decision making on behalf of the patient in a manner most consistent with what they believe to have been the last wishes of the patient with respect to emergency medical situations.
======================================================

PARAGRAPH 2

To give you a brief background, the family members are composed of the following - the wife (elderly around 80++ years old too with Alzheimer's Disease therefore unable to give sound opinion on the matter) and 5 children, all adults already in their late 40s and 50s. They are actually arguing as to what to do and how to go about the situation. We are aware of the legal document entitled Durable Power of Attorney in which the patient (when he is still able to make sound decisions for himself) appoints a person, usually the wife or children, to execute his last wishes in terms of resuscitation and life support with the help of machines in the event that a crucial decision has to be made. The patient was never able to sign and come up with his own Durable Power of Attorney but he did express at one point in his life when he was still well that he did not want any extreme life saving measures to be done in order to preserve his life if ever he had a stroke or cardiac arrest and the like. He never had the chance to put in writing though that is why the whole family is at a loss right now as to what to decide in the coming months.

RESPONSE: The answer to this paragraph is partially contained in my response above. Unfortunately, the family's indecision as to who should take the lead is commonplace and there are many reasons for this dynamic which can become ugly and sordid since in my experience with such matters (personal as well as professional) family members begin the bickering and power struggles begin to emerge which have more to do with material needs of individuals (i.e. money) and less to do with the medical needs of the patient. The family MUST decide upon a single voice to carry the DURABLE MEDICAL POWER OF ATTORNEY (DMPOA) which will then, decide all issues of a medical nature as if the patient were competent and capacitated to make their own decisions. The family may also appoint a Financial Power of Attorney to handle separate affairs and in many cases the Durable Medical Power can also be designated as the financial manager. Since no living will exists then, the designated DMPOA.

Now, in the US, here is where it can and does get even uglier. If there is dissension among who should carry the DMPOA and you have multiple people trying to make decisions then, those parties will have to apply for a court appointed GUARDIANSHIP of the patient and this supersedes all DURABLE POWERS or otherwise POWERS OF ATTORNEY. This, however, is an extremely long and costly process in the U.S. and if this patient is in any fragile shape (maybe not since they've survived 3 years in a vegetative state) then, often times the patients expire while the families are still battling in court.
======================================================

PARAGRAPH 3

I know the laws regarding such things vary in different parts of the world but based on what you know about medical jurisprudence in general, who has the right to decide in cases like this? The wife is not well also due to Alzheimer's. Do the siblings have the legal right to decide for their incapacitated father? What if they disagree with each other due to differences in religious beliefs? Some Christians are very adamant in their belief that it is a sin to not do all means to save a life, notwithstanding the fact that quality of life will be extremely poor if the patient is just hanging on for dear life with the help of machines. The others in the family believe that their Dad should not suffer any further and think that when the time comes that his body will give in, no extreme life saving measures should be done anymore. But there is also a sibling who is very strict with her Christian beliefs. Should they just follow the simple "majority wins" type of decision making? Or is there a legal consequence to be considered if and when they decide to just provide palliative care and not exert any extreme measures to preserve a life that is essentially not meaningful anymore because the patient is surely not comfortable being so incapacitated and unable to express anything, be it pain or discomfort. To add to that, he is already 88 years old and has already lived a full and meaningful life even before he got sick. Should he not be given the chance to rest when his body chooses to do so as we are sure that no one wants to live that way.

RESPONSE: Again, I believe much of the response to the content of this paragraph is already contained in the previous paragraphs. The absolute legal right to do anything will come from either the person designated as DMPOA or GUARDIAN of the Person. Both designations are legal ones and come about through special paperwork drawn up by attorneys. The hospital or the doctors are obligated to either follow the instructions of the RECOGNIZED representative voice of the family if it is the doctor's opinion or the hospital's opinion that such a person actually exists within the family. If neither the doctor nor the hospital can recognize such a person within the family then, THEY may at their discretion seek relief through their own legal means by getting an emergency guardian appointed through hospital attorneys. This person will in all likelihood be outside the family construct and have the authority to make medical decisions (whether the family likes it or not). Of course, the family may challenge that type of solution to the problem by filing a suit in court against the appointed guardian and claim their own guardianship but then, they need to start that proceeding sooner rather than later becomes once a guardian is selected (either on behalf of the hospital's part or the family's) it is very difficult, costly, and time consuming to reverse it. Much preferable for the family to simply designate a SINGULAR REPRESENTATIVE and then, allow them to operate as they see fit.
======================================================

I wish the family the best luck possible because these are neither easy nor financially cheap issues to deal with. I also once again thank you for your complimentary comments on the value of the information I've provided.

If you have no further questions or comments would you consider CLOSING THE QUERY at this time which will alert the network to process, archive, and credit this question appropriately for future reference?

You may always open a new series of questions directed to my attention simply by using the following website:

http://doctor.healthcaremagic.com/Funnel?page=askDoctorDirectly&docId=68474

This query required 46 minutes of physician specific review, research, and final draft documentation for envoy.

---