Time Robs Hope for Recovery

While serving a search warrant on a December afternoon in 1979, Minneapolis police Officer David Mack was shot in the neck and abdomen, triggering a cascade of events that left him in a persistent vegetative state.

He choked on his own vomit, depriving his brain of oxygen for several crucial minutes. Doctors gave up hope that he would ever regain consciousness.

Then he surprised them. After 20 months, the policeman came to, eventually gaining the ability to communicate with nods and to spell out words on an alphabet board.

Mack is the only known patient to regain consciousness after so much time in a persistent vegetative state brought on by oxygen deprivation. Doctors consider his recovery after 20 months mind-boggling.

Terri Schiavo has been in a persistent vegetative state for 15 years.

For all the legal, political and religious arguments that swirl around the Schiavo case, it is the faint hope of recovery that fuels her parents’ efforts to keep her alive with a feeding tube.

The overwhelming consensus among neurologists is that the chances are almost nil.

“After 15 years, it is truly hopeless,” said Dr. Howard M. Eisenberg of the University of Maryland Medical Center.

Dr. Ronald Cranford, a professor of neurology at the University of Minnesota who examined Schiavo in 2002, added: “The chances of her waking up or benefiting from treatment are zero.”

If you are in a room with Schiavo, her eyes do not track you, Cranford said.

CT scans show that the higher-thinking region of her brain -- the cerebral cortex -- has been severely damaged and scarred, he said.

To visitors, she may look as if she is aware. She sleeps and wakes. Her eyes move. She smiles at times.

It is an illusion of consciousness, doctors say.

Much confusion exists among the public about the nature of a persistent vegetative state, as compared with a coma or even being brain-dead.

A coma covers a range of conditions that can reflect minor to severe brain damage. Those patients are unconscious, lying still with eyes closed, unable to wake or speak. A person in a coma may respond to pain and there are some reflexes, such as gag or swallow responses.

Brain death is a severe loss of cells in the brain so that it cannot carry out any normal functions. Parts of the brain involved in high-level thinking are severely damaged or destroyed, as are the most primitive parts that control autonomic functions, such as breathing.

Brain-dead patients may be kept alive on life support, but if that support is stopped, they die within minutes.

A persistent vegetative state is somewhere between coma and brain death. As many as 35,000 Americans are in such a state at any one time.

In that condition, the primitive parts of the brain continue to function and the patient goes through normal sleep-wake cycles and is able to breathe.

But patients lose all meaningful contact with the world because of damage to higher-functioning parts of the brain. Such patients show no awareness, no ability to interact with others and no evidence of language comprehension.

They do display random tic-like behaviors, apparently grimacing or smiling, making sounds, and moving arms and legs. Such patients can even squeeze a hand in response to a caress.

“The problem frequently is that people who are involved with the patient over-interpret this very rudimentary behavior and develop unrealistic hopes,” said Eisenberg of the University of Maryland. “That is not unusual, but it makes for a very difficult problem.”

There are essentially two causes of a persistent vegetative state. The first is head injuries that damage a part of the brain. Patients with this condition have a better chance of recovery because they may not have suffered widespread death of brain cells.

The second cause is oxygen deprivation, typically through a heart attack or stroke.

Once the blood supply is stopped, the lack of oxygen can kill the cortex, “the part of the brain that makes us human,” Eisenberg said.

Schiavo and Mack both suffered this form of injury.

After Mack awoke, he remained almost entirely paralyzed. He could smile and frown, but he could not speak and had trouble swallowing. He would go through periods of depression, though he said he didn’t regret the decision to be kept alive.

Mack died of an infection 5 1/2 years after regaining consciousness.

According to guidelines from the American Academy of Neurology, a vegetative state can be judged to be permanent rather than persistent after 12 months if it results from traumatic injury or after three months if it results from heart attack, stroke or other illness.

“The chance for recovery after these periods is exceedingly low,” the guidelines note.

Most patients die in two to five years due to infections, general systemic failure, respiratory failure or strokes. It is unusual for a patient to survive for 10 years, according to the committee, and the odds of surviving for 15 years vary from 1 in 15,000 to 1 in 75,000.

The panel identified three patients, however, who survived for 17, 37 and 41 years.

In general, children who enter a persistent vegetative state do not survive as long as adults.

The guidelines were set off partly in response to the case of Karen Ann Quinlan, whose parents sued to have her removed from life support after she had been comatose for 11 months after consuming alcohol and tranquilizers.

That case established the right-to-die debate in the U.S. Quinlan survived for nine years after Joseph and Julia Quinlan took her off a respirator in 1976.

The hopes of Schiavo’s parents are fueled in part by pronouncements from physicians such as Dr. William Hammesfahr, a neurologist who runs the Hammesfahr Neurological Institute in Clearwater, Fla.

“Her chances of getting better are excellent,” he said in an interview Monday. “They are overwhelming, with the proper therapies.”

Among other treatments, Hammesfahr proposed placing her in a hyperbaric chamber to force more oxygen into her blood and administering drugs to dilate blood vessels and increase blood flow to the brain. He also suggested using physical, speech and occupational therapy, and perhaps omental transfer, in which fat from the stomach is transplanted into the brain, to increase blood flow.

Hammesfahr said he had treated 250 patients and that 98% of them showed “significant improvement.”

Cranford, however, described such treatments as absurd.

“The idea that she would respond to hyperbaric oxygen or vasodilator therapy is totally bogus,” he said.

Dr. James Bernat, professor of neurology at the Dartmouth Medical School in Hanover, N.H., agreed. “There is no scientific evidence that it helps,” he said.

Schiavo’s parents have expressed hope that science may one day come up with a solution to their daughter’s plight.

Indeed, scientists have begun experimenting with stem cells in animals to regenerate neurons, with some success.

But the thought of rebuilding whole sections of the brain is beyond reasonable speculation, doctors said.

“When you are talking about what is currently regarded as irreversible neuronal damage, I don’t know what kind of treatment in the future could bring those back to life,” Bernat said. “It sounds like science fiction to me.”