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LICC attending physician quoted in Medscape Medical News

Quoted in the following article is Sotirios Kassapidis, MD, an attending physician at Long Island Care Center.

As appeared on Medscape Medical News, April 1, 2005

Despite Rhetoric in Schiavo Case, PVS Diagnosis, Prognosis Standards Reliable²
by Paula Moyer, MA

March 30, 2005 (updated April 1, 2005) ‹ Underneath the rhetoric and polarized emotions in the Terri Schiavo case, the procedure for diagnosing a persistent vegetative state (PVS) consists of established standards, and the prognosis of a patient's recovery can be accurately determined, according to several medical experts.

In separate interviews with Medscape, they stressed that the diagnosis of PVS is made according to a standard protocol outlined by a practice parameter statement published by the American Academy of Neurology (AAN).

That statement notes that patients in PVS have:

  • No evidence of awareness of self or environment and an inability to interact with others;
  • No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli;
  • No evidence of language comprehension or expression;
  • Intermittent wakefulness manifested by the presence of sleep-wake cycles;
  • Sufficiently preserved hypothalamic and brainstem autonomic functions to permit survival with medical and nursing care;
  • Bowel and bladder incontinence; and
  • Variably preserved cranial nerve (pupillary, oculocephalic, corneal, vestibulo-ocular, gag) and spinal reflexes.

The AAN also has developed standard procedures for making the PVS diagnosis. "The PVS diagnosis is the result of a clinical evaluation supported by imaging and supportive data such as electroencephalogram [EEG]," said Roger Albin, MD. He is a professor of neurology at the University of Michigan in Ann Arbor. "The diagnosis comes as the result of examining the patient, observing the patient, and making repeated evaluations over some period of time ‹ most people would say a fair number of hours over several days."

"The EEG shows if there is any brainwave functioning," said Sotirios Kassapidis, MD, an attending physician at Long Island Care Center in Flushing, New York, where he is a pulmonary critical care specialist. He stressed that the physicians who diagnosed PVS in Ms. Schiavo followed these procedures.

The imaging study, typically magnetic resonance imaging (MRI), will show extensive damage to the forebrain, Dr. Kassapidis said. The type of damage will depend on the etiology, whether hypoxic-ischemic encephalopathy, as in Ms. Schiavo's case, or hemorrhage due to trauma. Although the prevalence of PVS is unknown, Dr. Albin said that several thousand people in the U.S. are estimated to be in PVS.

Dr. Albin pointed out that hopeful family members and even physicians can be confused by some of the typical phenomena seen in individuals in PVS. "They can have a variety of spontaneous or stimulus-solicited movements, and can look purposeful," he said. The presence of these movements is the reason repeated evaluations are necessary, he said. Dr. Albin stressed that the diagnosis cannot be made from a single bedside assessment; it takes repeated, prolonged observations along with the imaging studies and EEG.

Bruce Sigsbee, MD, emphasized the importance of the physician's expertise in making the diagnosis. "With a competent neurologist, the diagnosis can be made with a high degree of certainty," he told Medscape. Apparently Ms. Schiavo underwent computed tomography (CT) but not an MRI. A CT in cases like this, Dr. Sigsbee said, "can provide evidence of severe cerebral injury." Although a CT would not be as complete, "it still would be an excellent source of information," he said.

Dr. Sigsbee, a neurologist in private practice at Penobscot Bay Medical Center in Rockport, Maine, added that, if the AAN guidelines are followed carefully, the possibility of misdiagnosis is remote. "If important, most of us would ask for a second opinion," he said.

The assumption that a patient who has been in PVS for several years will not recover is uniformly true, Dr. Albin said. "The literature and the AAN guidelines indicate that PVS from hypoxic-ischemic encephalopathy for three months is considered to be permanent," he said. "If the condition results from head trauma, PVS is considered permanent after it continues for a year." In a case in which PVS has continued for several years, the chance of recovery is "virtually zero," he said.

Dr. Sigsbee added that no example of recovery has been documented after 15 years of PVS, as in the Schiavo case.

When stories circulate about such patients recovering, the diagnosis of PVS was probably inaccurate, Dr. Albin said. They may have, been, instead, in a minimally conscious state, which is characterized by some evidence of the patient's intermittent awareness of his or her surroundings. Minimally conscious patients show at least intermittent awareness of their environment by making the same responses to the same stimuli, by more consistently responding to commands, and otherwise showing purposeful behavior, according to Dr. Albin.

Patients in a minimally conscious state have a far better chance of recovery, he said.

Dr. Sigsbee said that for patients in the minimally conscious state, "there is some evidence of a behavioral response to visual, auditory, tactile, or noxious stimuli." However, he pointed out that when the potential for diagnosing minimal consciousness exists, "[o]ne must be very careful to carefully analyze the behaviors. It is easy to read a behavioral response into nonpurposeful behaviors, particularly if bias exists." All of the experts stressed that physicians can help avoid situations like the Schiavo case by consulting with their patients and family members about their wishes and encouraging them to document those wishes in a written advance directive, and by appointing a healthcare proxy, also known as medical power of attorney. "The best thing physicians can do is to encourage patients and make them aware of what their choices are, and to have open discussions with family members," Dr. Albin said. He stressed that the best time to have such conversations is before a crisis occurs.

Dr. Sigsbee also emphasized the importance of the healthcare proxy. "Each circumstance is sufficiently different that advance directives are vague and cannot be easily applied to each occurrence," he said. The healthcare proxy can help interpret the patient's wishes for those nuanced individual circumstances and may also ward off the central problem in the Schiavo case, the family conflict. "As a physician, it is important to try to thwart any family conflicts that may interfere with the care of the patient," he said, noting that it is not always possible to achieve this goal.

Dr. Kassapidis agreed. "The most important thing that can happen is direct communication between the physician and family members" if the disaster has occurred and the patient can no longer speak for himself or herself. "The physician needs to be straightforward with the family and ask, 'what were her wishes?' " he said. "If those wishes had been outlined in the beginning, these problems could be avoided." He urged physicians to encourage all patients to document their wishes.

Reviewed by Gary D. Vogin, MD

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