Vegetative State in Forensic Medicine
Introduction
Vegetative state is a chronic long-term state in which the patient has no mental and cognitive functions, and no communication with the environment, but can be awake and have a regular sleep-wake cycle; 5%-10% of the patients that go into coma cannot gain consciousness and finally develop a vegetative state (Figure 1). The disease was first described in 1940 by Ernst Kretschmer and he named it apallic syndrome. In the following years, other people conducted more studies on the disease and each explained it under a specific name and finally an American neurologist named it vegetative state (3). After four weeks of the onset of the clinical symptoms, the patient is classified under sustainable or persistent vegetative state. If the state continues and there is no recovery, the patient is classified under persistent or permanent vegetative state after one year in case the cause of disorder is trauma, and in non-traumatic cases after three months and six months based on the American and British sources, respectively (21).
According to the texts and articles in this realm, the challenging issue in other countries is after what period and based on what criteria the treatment can be discontinued and an end can be put to the life of the patient; for instance, in the United States to separate the supporting equipment (feeding tube, serum, etc.) prosecutor`s permission is required, and this can be done in case there is no hope for the cognitive improvement of the patient (2). According to the British Association of Physicians, the action should not occur within the first year of the onset of the disease (22).Of course the disease should not be considered as death, generally in the legal system of limited countries it is considered as death (12). Since Iran jurisprudence recognizes such patients alive, it does not allow the cessation of treatment in them; consequently, it is not the topic of discussion in the current study. In the studies on how to determine the amount of compensation in such cases, which is the main challenge of Iran Forensic Medicine Organization, no specific points were observed in the legal discussions. For many years, the disease is discussed by the forensic physicians and their issue is how to determine the compensation. Can the problems of the patients be considered as a single lesion under articles 675 or 676 of the Islamic Penal Code? Or there are different compensations for the different disabilities caused for the patients? The current study addressed these topics and their related issues.
Before starting the discussion, the symptoms and how to diagnose the disease are reviewed quickly. In such patients, two basic parameters of consciousness should be distinguished that is awareness and awakening. Awakening is a state that the eyes are open and there are some levels of motor consciousness, which is against sleep in which the eyes are closed and there are no movements. Awakening in ordinary state is correlated with conscious awareness, but in such patients awakening and awareness are separated maybe due to the separation of the thalamus and parts of the brain stem that control awakening from the upper parts that control awareness (14). Although patients with persistent vegetative state are awake, cognitively, they are not able to identify the issues around them and are not even aware of their status (12). Most of them are not responding to the external stimuli; in some cases, they can respond, but the responses are definitely not purposeful and conscious. Despite the patients in coma, these patients open their eyes when eating and they can swallow. The eyes of such patients may be fixed or move independently or have limited ability to follow objects. The patients have sleep-wake cycle and might stay awake for a long time and not fall asleep. Sometimes it might be assumed that they have relative consciousness, due to behaviors such as laughing and crying (13). Sometimes the person can say an inappropriate word, which is meant to save some islands of the cortex. Seizure often occurs in such patients. The word vegetative is selected purposefully in such patients, since despite the fact that they do not have intelligence activity, cannot communicate with the others, and do not understand the sensory signals, they can manage their autonomous activities. They breathe, have a stable blood circulation system, and consequently rarely need supportive equipment for life.
Physiopathology
Lack of awareness in the patients is due to extensive bilateral cortical injury, injuries due to subcortical connections in the hemispheres and the white substance of the brain, and thalamic necrosis (23). Based on the studies and employment of parametric mapping, positron emission tomography (PET), and functional magnetic resonance imaging (FMRI), it was observed that the major damaged areas of the brain in patients are bilateral frontal and parietotemporal lobes in association cortex (17). In the patients, there might be some cognitive activities, that is a painful stimulus can activate the primary sensory cortex in the parietal lobe, as a sound stimulus can activate the primary hearing center in the temporal lobe, but since the connection of the primary centers is cut with the secondary and advanced centers that are responsible for the analysis and interpretation of the stimuli, ultimately, the patient is not able to understand them (19). These points are proven by the somatosensory evoked potentials. Studies showed that in such patients, the functional relationship between the sleep-wake cycle stimulator (the ascending reticular activating system (ARAS) and the polymorphic (precuneus) association cortex, which plays a role in the formation of awareness, is interrupted, and this also contributes to the lack of conscious understanding of the senses. Brain white matter diffusion in these patients is also effective in sensory disorders (20). This damage to focal lesions is a nerve fibromyalgia, and in disseminated disorders (brain hypoxia) is the accumulation of residual fibers around the dilated brain ventricles. In addition to disruption of these communication pathways, the association between certain areas of the cortex, thalamus, and cortex (cortico-thalamic-cortical pathway) is affected. It is observed that the improvement of consciousness of these patients is parallel to the improvement of this pathway (17). Basically, the establishment or maintenance of white matter communication between the posterior parts of the brain, the frontal lobe, and the thalamus, and the maintenance of brain blood flow in the cortex can predict a minimal improvement in the knowledge of these individuals despite significant anatomical lesions (25). Symptoms of these patients are not necessarily due to the reduction in the number of neurons, but can also be due to changes in the functioning of the neurons in sensitive areas of the frontal cortex, parietal, and of course thalamus nuclei (18). However, it is very difficult to assess the extent of remaining cognitive performance (20).
Causes of the disease are divided into three major groups:
- Traumatic
- Non-traumatic
- Brain degenerative and metabolic disorders (increased or decreased blood glucose, elevated blood calcium, liver or kidney failure, and severe congenital malformations of the nervous system)
Diagnosis
Identification of these patients is based on clinical symptoms. MRI can help to identify the cause; PET and electroencephalography (EEG) can be also used, but there is no necessity (11). Based on the recent sources, the diagnosis criteria of the disease are as follows:
1-based on the investigation, there is no evidence regarding the awareness of the individual about himself or the environment. This awareness can include memory, thought, and excitements. Awareness is not a single function and brain injury can eliminate parts of it selectively. In such patients, there should be no laughing in response to a friend's visit, attempting to reach an object, and proper speaking. Blinking in response to loud noise or kicking off or shouting, pulling back the hand, and strong muscle pressure are not clinically important. Currently, there is no single clinical symptom or specific laboratory test to diagnose a person's awareness. FMRI can identify the remaining cognitive power in such patients (12).
2- There should not be found evidence of a sustained, repeatable, purposeful, or optional response to tactile, visual or auditory stimuli. Of course, there might be a number of self-contained movements in such patients, but without a specific purpose. Painful stimuli can produce a non-targeted response in the organs (bending or opening), even the eyes may reflexively turn towards the sound or follow a moving object transiently, but cannot be fixed on a target (12).
3. Speech impairment in a manner that there is no understanding of the words or the expression of the word.
4- Presence of a sleep-wake cycle, laughing, and yawning.
5. Functionality of the autonomic hypothalamus and brain stem.
6. Urine and stool incontinence.
7. Various levels of spinal cord and spinal reflexes may be preserved (9, 10).
8. The cause of the disease should be clear.
9. Drug complications (neuromuscular blockers) and metabolic reasons as the cause of a lesion should be rejected, although drugs can lead to a brain hypoxia and vegetative state that is accepted in such cases.
10. There should not be any curable brain structural abnormalities (tumors) (12). As a result, MRI as a very powerful tool for neuropathological evaluation of these patients is necessary (24).
11. To determine the persistent vegetative state, depending on the cause, there should be from six months to one year past from the onset of the symptoms.
In the above mentioned criteria, items 4 and 5 are not necessary, but the other items should be confirmed (12).
At present, there are no tools to assess the extent of consciousness. Diagnosis of the patients is based on two sources: A precise clinical history that the source is the patients` relatives and a careful monitoring of patients` spontaneous behavior. Clinical evaluation of the patients requires frequent screening at different sessions, since a patient that is not in vegetative state (a condition with a brief level of consciousness) can have varying periods of consciousness and by one time examination some of them may be classified as patients with vegetable state. Another important point in this section is that to confirm the diagnosis at least two physicians at two different sessions should separately approve the diagnosis (12). It should be noted that there should be no hurry to raise the diagnosis, and if there is any doubt, the patient should be re-examined and at another session (16). It is important to observe these points in diagnosis; studies in UK found that about 43% of patients were misdiagnosed (4). In fact some of the patients had lower level of consciousness (5). The disease may be caused during the course of vegetative state (15). In the study by Monty et al., some cases of misdiagnosis were reported (6). The main reason for misdiagnosis of such patients was the disability of patients such as blindness (12).
Course of the disease
Many of the patients (about 50% of traumatic and 20% non-traumatic cases) recover within some weeks (3).
The factors affecting in the recovery of such patients are: 1- Extent of injury, 2- Age (the younger patients have higher chances of recovery), 3- Mechanism of the disease (traumatic patients have a higher chance of recovery), 4-Time elapsed from the injury (7) (by increasing the elapsed time, the chance of recovery decreases and after one year, the chance of recovery is reduced to zero)(8, 22); some rare cases of recovery after one year are reported.
Methods
By referring to PubMed, MEDLINE, and other authoritative databases, relevant and recent articles were searched and evaluated. The required information was recorded, negotiated with a number of forensic physicians, and finally a summary of the issues was provided.
Results
To avoid misdiagnosis and appropriate evaluation of the patients, it is suggested to consider the confirmation of the diagnosis by at least two neurologists; it should be done separately and at two different sessions. Meanwhile, after one year of the onset of the symptoms (which are less likely to improve in such patients) the documents and records should be completed for the final comments.
Discussion
Currently, the forensic medicine centers routinely diagnose the disease in the patients usually by one visit conducted by a neurologist, sometimes in less than a year from the onset of the symptoms, and on the basis of that the opinion is issued. According to the above mentioned points, this procedure can lead to misdiagnosis; therefore, adherence to the presented diagnostic procedure is suggested to prevent misdiagnosis. But, to determine the damages in such patients, there are different views among the experts, which lead to a lack of unity of the issued opinions by different centers. Some believe that given the fact that the brain is damaged as the center of the body control and all disturbances are caused due to it, then a single compensation is sufficient for the patients. There are defects from different viewpoints; first, if a patient has speech impairment and organ paralysis due to stroke, the same experts believe that the patient can receive separate compensations(speech impairment and organ paralysis) and do not consider the injury of the brain; and patients with more limited brain injuries that have more neurological injuries, receive larger compensations; therefore, this justification is not accepted; and finally, the Islamic Penal Code does not apply a single compensation to the whole brain, which can be employed to deal with such patients. Therefore, it seems that in dealing with patients with brain lesions the law mainly considers the lesions created in the peripheral organs. There is no consensus among the experts who believe to independently calculate damages to peripheral organs and there are differences from 3 to 8 compensations for such patients. A review of the damage in such patients can lead to a conclusion. Due to lack of awareness in such patients, they are incapable and have no thrift. Although the primary sensory cortex may be healthy in the patients, it is shown that their analytical and sensory regions are impaired, and thus the patients are not able to understand the peripheral senses (visual, taste, smell, hearing, sense of pain and heat, etc.); for instance, from the visual point of view they are not different from a blind person. Urine and stool incontinence are among the main symptoms of such patients. Sexual dysfunction (sexual intercourse and pleasure) is another benefit that is lost in such patients. Since these disorders are proven by several studies using different diagnostic tools, there should be no misdiagnosis; once the diagnosis is finalized all of the damage should be confirmed for the patients. Muscle weakness in such patients varies, and according to the expert's examination and determining the severity of weakness, compensation is determined. According to the discussion, it is not possible to consider a single compensation for these people based on the justification that the center of control of the actions in the brain is damaged, since, as already stated, the damage caused in such patients are not specific to one special area. It seems that the damage to such patients is consistent with Article 541 resulting in various damages in the organs of the body due to an accident. Therefore, it can be concluded that each of the defects has its own compensation. This point is also mentioned in Article 544 indicating that each of the damaged benefits should be addressed and evaluated separately. Another point, which is to the detriment of defining a compensation for this problem, is Article 543 in which there are no quadratic conditions mentioned for the patients regarding the interference of compensations. Therefore, each of the defects seems to have its own independent compensation. The logic referred to in Article 675 is the thrift, which is the center of thinking, judgment, and solving problems etc. that its control centers are in the dorsolateral prefrontal cortex in frontal lobe, but in such patients, the damage is much wider than that; therefore, although such patients lack awareness and thinking power, they are of course included in this article, the damage of such patients is beyond that. Since the cause of urine and stool incontinence in these people is the damage to the central nervous system, their damage is not justified by articles that indicate defects due to perineal stroke. One of the benefits that these patients lose is sexual dysfunction, which affects the ability of intercourse in males, and since perception of the senses is impaired, the pleasure of intercourse in females and males is also lost. Some experts believe that in such patients, under these clinical conditions, the existence or absence of a number of benefits is not important and is inapplicable in their clinical condition and should not be considered. In response, it should be noted that the responsibility of the expert is to give all the issues raised in accordance with the law, since with this justification one cannot answer the question of why in the holy religion the punishment is intended to cut off the paralyzed organ.
Conclusion
- Completion of the case and making a final comment should be necessarily done one year after onset of the disease symptoms (the symptoms of the disease in such patients is less likely to improve).
- The diagnosis should be confirmed, after examination of at least two neurologists, separately, and at least at two different sessions.
- Employment of the criteria presented in the diagnosis and using them as a checklist can also be helpful for forensic experts.
- According to the explanations provided for physiopathology, it is clear that the damage to these patients is not limited to a specific area; therefore, it is impossible to close the case with a single compensation.
- According to Article 675, such patients are liable to the dementia compensation.
- Urine and stool incontinence in patients are referred to in Articles 704 and 705.
- Sexual dysfunction in males is included in Articles 706 and 707 and in females Article 706.
- Due to the development of sensory defects in such patients, according to Article 708, they are liable to compensation.
- Speech impairment in these patients is subject to Article 698.
- The fact is that, as explained in terms of physiopathology, such patients do not have a sense of smell; therefore, Article 693 applies to them.
- Such patients do not have visual and hearing comprehension, and in fact they are not different from blind and deaf individuals; therefore, Articles 689 and 682 applies to them.
- Seizures are common in such patients, which may result in separate compensation in case of occurrence.
- In case of nasogastric intubation or similar instruments, it is subject to independent compensation depending on the condition.
- Due to the fact that the severity of the organ weakness varies in such patients; therefore, according to Article 564, and the severity of the weakness of the organs, compensation is applied to it.
- Recurrent pneumonia and bedsore are liable to separate compensations.
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