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Kate Bainbridge, a former schoolteacher who was similarly misdiagnosed in the 1990s in England, has since recovered enough to communicate by using a computer. "It really scares me to think what might have happened to me had I not had the scans," she wrote in an e-mail to a journalist in 2007. "They show it was worth carrying on even though my body was unresponsive."
This year, Laureys further challenged presumptions of the quality of life for postcoma patients with a survey in the British Medical Journal of locked-in patients. Such people sustain a brain injury that results in paralysis so severe they can control only their eye movement, even as their consciousness network remains intact. The journalist Jean-Dominique Bauby, perhaps the most famous such patient, earned fame through a memoir, The Diving Bell and the Butterfly, which he dictated by blinking.
In the immediate weeks after their injury, locked-in patients show intense activity in a region of the brain associated with anxiety and emotion, but they eventually adjust. Laureys' survey of 168 locked-in patients found that while a minority--just 7%--reported life to be "miserable" and were lobbying to be euthanized, a vast majority said they were "happy" despite their condition. "That result showed that we should be very careful not to presume that we know the subjective experience of a noncommunicative patient," Laureys says. "That has profound implications for families and doctors considering whether to withdraw life-sustaining treatment."
But those implications can cut two ways. Truly vegetative patients who remain awake but unresponsive for more than 12 months following traumatic brain injury or three months after cardiac arrest or stroke are classified as permanently vegetative. The U.S. Supreme Court ruled in 1990 that such patients may have their feeding tube withdrawn if they have a living will, if their legal proxy so desires or if there is strong evidence that the patient would want to die.
There is no known time limit, however, for when a minimally conscious patient might suddenly return to full awareness. In 2003, 39-year-old Terry Wallis of Arkansas emerged from minimal consciousness and regained fluent speech after lingering in a nursing home for 19 years after a car crash. Using diffusion tensor imaging, a novel brain-scanning technique that maps the intact internal cables in the brain, Schiff found in 2006 that Wallis' brain had undergone axonal sprouting. New connections had been made among existing neurons.
All families with a vegetative loved one imagine that he or she will be the next Wallis, though few are. So even with the dignity and perhaps comfort of the patient on the line--not to mention the welfare of the family's wallet--it can be agonizingly difficult to pull the plug. "The right to die is an important principle," Laureys says. "But doctors must also be clear that we can't always give a certain prognosis."