Coma and Disorders of Consciousness

Severely brain-damaged patients pose major challenges regarding treatment and end-of-life issues. Advances in medical technology increasingly confront physicians, social workers, and lawyers with ethical issues. This situation is dramatically illustrated by the case of Julia Tavalaro, who survived a brain trauma and was transferred to a nursing care center where she was called “the vegetable” for over 6 years, although she was conscious and sensate (Tavalaro and Tayson, 1997). In Italy, the story of Eluana Englaro, a 36-yearold woman who remained unconscious for 17 years after a car accident, became the focus of a court battle between supporters and opponents of euthanasia (Luchetti, 2010). Stories of this kind have inspired several social, political, and religious groups to emphasize that these patients have rights to be fully considered as human beings by also recognizing their right to die (Table 17.1) (Borthwick, 1995; Velez, 2005). Moreover, important figures in the history of the right-to-die movement (Table 17.2) have provided the background for examining the advancement of clinical decision-making, including when to use or not to use technologies such as ventilators and artificial nutrition and hydration. Indeed, the invention of the artificial respirator in the 1950s has assisted many patients to sustain their cardiac circulation, who otherwise could not have survived their acute brain damage and coma. This treatment has led to the redefinition of death based on neurologic criteria (i.e., brain death or irreversible coma with absent brainstem reflexes: Laureys, 2005) and to the identification of states of profound paralysis causing pseudocoma (i.e., locked-in syndrome (LIS): Laureys et al., 2005). Nevertheless, the decision to withdraw or withhold such