Frequently asked questions
Q. Doctors have determined that Terri Schiavo is in a persistent vegetative state. What does that mean?
A. The diagnosis of a vegetative state means a patient is physically awake but remains mentally unconscious. She has lost her ability to think and awareness of her surroundings. Although she opens her eyes, breathes on her own, and moves reflexively, patients in a vegetative state typically are incontinent and cannot feed themselves or communicate. The condition is considered ''persistent" if it lasts more than one month in patients like Schiavo whose brains were damaged from lack of oxygen.
Q. How is this different from being brain dead or being in a coma?
A. Patients who are brain dead are unconscious, cannot breathe on their own, do not respond to any stimulation, and do not show any reflexive movements, such as gagging if doctors touch the back of the throat or blinking if doctors touch the whites of their eyes. Their heart is beating, but they show no activity on an electroencephalogram, or EEG, which measures electrical impulses in the brain.
Patients in a coma can't be roused from the state of deep sleep that their brain has entered. They may breathe and show some basic reflexes, but far less than someone in a vegetative state. An EEG shows a low level of brain activity.
Q. How do doctors diagnose a vegetative state?
A. Once the patient emerges from a coma, doctors conduct a neurological examination that starts with attempts to get the patient to interact. They speak to the patient, touch the patient, and see whether there is any consistent response verbally or nonverbally. They typically ask the patient to squeeze their hand and blink a certain number of times, for example, testing to see whether they can meaningfully respond. Patients in a vegetative state will not respond in any predictable way, said Dr. Stephen Salloway, a staff neurologist at Rhode Island Hospital and professor of neurology at Brown Medical School. The tests will be repeated at regular intervals. Doctors may conduct EEGs and MRIs, although these tests are not definitive.
Q. Pictures show Schiavo with her eyes open and smiling. Do these facial expressions mean anything?
A. Patients in this state typically sleep and wake normally. But their eyes can rarely, if ever, track movement. They often make noises and may grimace or smile, but these are reflexive movements that are not consistent responses to people or the environment, according to Dr. Viken Babikian, a neurology professor at Boston University School of Medicine. The independent court-appointed guardian in Schiavo's case said videotapes show instances where she appears to respond to her mother, but ''these are not repetitive or consistent."
Q. Can a patient in a persistent vegetative state recover or gain some higher-level functioning?
A. They may make small gains early on, with the help of medications and rehabilitative therapy, but after a few months, they have almost no chance of regaining consciousness, according to Dr. Douglas Katz, associate professor of neurology at Boston University School of Medicine. The more time that elapses, the dimmer the prognosis. Schiavo has been unconscious for 15 years.
Tests of Schiavo's brain show that her cerebral cortex, which controls thinking, has softened and decayed, according to a document filed by the guardian. The guardian also said Schiavo has no reasonable medical hope of recovery.
Q. Is there another mental state between vegetative and fully conscious?
A. Some doctors distinguish a condition called minimally conscious, but the diagnosis is still controversial. These patients show intermittent awareness of themselves and others and may occasionally be able to follow a command or meaningfully track an object with their eyes. They may also occasionally communicate with gestures or with a simple yes or no. Some patients with this condition have been misdiagnosed as vegetative, and these cases have occasionally been touted as miraculous recoveries, according to Katz, medical director of the brain injury program at HealthSouth Braintree Rehabilitation Hospital.
Q. Would a patient in any of these conditions legally be able to make medical choices for themselves?
A. No. Patients must be capable of understanding their condition and treatment options. If the patient has designated a health proxy to act for them, doctors would contact that person. If the patient left written directions, those may guide doctors. But if, as in the Schiavo case, there is no proxy or directions, doctors turn to family members. If relatives can't agree, doctors then turn to a hospital ethics committee and rarely to the courts.
Alice Dembner
