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Ethics Consultations and Patients With Neurological Diseases

      To the Editor: The article by Swetz et al
      • Swetz KM
      • Crowley ME
      • Hook CC
      • Mueller PS
      Report of 255 clinical ethics consultations and review of the literature.
      called attention to ethical dilemmas in daily hospital interactions and has stimulated fruitful discussion about how to deal with ethical issues among hospital staff and, most importantly, between caretakers and patients. It effectively promotes the use of formal ethical consultation. From our perspective, neurological syndromes generate diverse ethical dilemmas that may require specific attention.
      Treating patients in a vegetative or nearly vegetative state is costly and agonizing. Neurophysiologic studies provide no easy answers for treating these patients. For example, 12% of patients in a vegetative state and 77% of those in a nearly vegetative state show event-related electrical potentials supporting the existence of semantic processing, ie, the ability to comprehend the meaning of language.
      • Schoenle PW
      • Witzke W
      How vegetative is the vegetative state? preserved semantic processing in VS patients—evidence from N 400 event-related potentials.
      Patients and family might wonder whether medical care is generating more suffering than it is relieving. Health care professionals are committed to exert any effort to save and prolong life to the extent modern techniques allow. The responsibility for the life of a patient has been borne on many shoulders, including teams of ethical consultants and state legislators.
      Dementia, psychosis, and other devastating deficits compromise patient judgment, potentially calling into question autonomy and consideration of preexpressed or family-inferred patient wishes. Motor neuron disease creates the dilemma of extending conscious life in a crippling state, in which a person could be bound to an artificial respirator and completely dependent. Many neurological diseases, such as Huntington chorea, remain incurable and create a dilemma about whether an unaffected relative should be tested for the disease-causing mutation.
      What of the individual who becomes aware, from incidental discovery on a head imaging study, of a predisposition to a disease leading inexorably to disability and lifelong dependence? On the one hand, diagnoses based on imaging hold promise for assessing metabolic and anatomic anomalies, including those related to altered function or irreversible injury. On the other hand, diagnoses based on imaging also raise compelling questions about the precautions needed as patients seek earlier diagnosis of diseases for which cures or even effective symptomatic treatments do not yet exist.
      • Illes J
      • Racine E
      Imaging or imagining? a neuroethics challenge informed by genetics.
      Who will assume primary responsibility for offering ethical consultation for these questions?
      We would find it informative if Swetz et al would subcategorize the neurological cases (intensive care unit patients, stroke patients, neurodegenerative/genetic diseases) so that readers can have a better understanding of the types of ethical issues that are raised during hospitalization of these patients. Furthermore, it would be interesting to know whether these formal consultations were comparable to the presumably more frequent informal consultations regarding similar conditions and whether cases that were resolved before the multidisciplinary team was assembled were different from those after the team was assembled. The assessment of a tool such as the multidisciplinary ethics team requires a clear understanding of the team's consultations on similar dilemmas. Because cases were gathered in the course of a decade, time trends in the recommendations of the team when faced with certain questions would also be of interest.

      REFERENCES

        • Swetz KM
        • Crowley ME
        • Hook CC
        • Mueller PS
        Report of 255 clinical ethics consultations and review of the literature.
        Mayo Clin Proc. 2007; 82: 686-691
        • Schoenle PW
        • Witzke W
        How vegetative is the vegetative state? preserved semantic processing in VS patients—evidence from N 400 event-related potentials.
        NeuroRehabilitation. 2004; 19: 329-334
        • Illes J
        • Racine E
        Imaging or imagining? a neuroethics challenge informed by genetics.
        Am J Bioeth. 2005 Spring; 5: 5-18

      Linked Article

      • Ethics Consultations and Patients With Neurological Diseases–Reply–I
        Mayo Clinic ProceedingsVol. 82Issue 12
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          We thank Dr Algom and colleagues for their interest in and comments regarding our recent article. Herein, we respond to the queries in their letter. Of the 255 patients in our series, 47 (18%) had a neurological diagnosis. Of these 47 patients (mean age, 68.0 years; median age, 74.5 years), 15 (32%) were diagnosed as having an ischemic stroke; 10 (21%), an intracranial hemorrhage; 7 (15%), traumatic brain injury; 3 (6%), dementia; and 2 (4%), amyotrophic lateral sclerosis. The remaining 9 patients (19%) were diagnosed as having a variety of other neurological conditions (eg, paraneoplastic encephalopathy, central nervous system vasculitis, granulomatous leptomeningitis, myasthenia gravis, generalized dystonia, and central nervous system lymphoma).
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