enabling death

March 8, 2007 9:10 AM

Someone has taken a serious fall and is in a coma. How long to wait before pulling the plug?

Is there some established ethical time frame?

posted by four panels to science & nature (19 comments total)

yikes! how on earth could anyone answer this? it is a very personal decision that must be made by the family. see media coverage of Terry Schiavo for a lively debate.
posted by PercussivePaul at 9:15 AM on March 8, 2007

Please tell us this is a hypothetical question, and not one you are asking us to answer for you on behalf of a person currently in a coma.
posted by caution live frogs at 9:17 AM on March 8, 2007

You do know that there are multiple types of comas, reasons for comas, types of injury that cause comas, and that the prognosis is something that you really need to talk to a doctor about, yes?

You also do know that hypothetical-filter is frowned upon here, so you're posting this about a real situation, yes?
posted by croutonsupafreak at 9:22 AM on March 8, 2007

No ethical doctor would diagnose on the basis of this scanty information. Better contact Dr Bill Frist.
posted by DU at 9:25 AM on March 8, 2007

Is there no living will, or person who knows what the patient would wish?
posted by hermitosis at 9:32 AM on March 8, 2007

The short answer is, No. There is no standardized time frame created by The Ethicists for which to remove life support from someone in a coma.

The next part is that the hierarchy of people who can make the decision to remove life support probably are as follows:
1. The Patient, either by voicing their opinions themselves, or through an Advanced Directive that they have completed prior to the incident.
2. The person with Durable Power of Attorney as delegated by the patient (hopefully prior to the incident).
3. If none of these exists, then probably "The Next of Kin," the choosing of whom can be complicated in itself. (See: Terri Schiavo)

The decision to remove life support is based on any number of factors. Regardless, there are many different kinds of life support and many different levels of consciousness and, obviously, it is not as simple as you would like it to be.

Use this as a lesson: Create and Advanced Directive now and talk to your family about your desires. And get them to talk to you about their desires.
posted by sarahnade at 9:47 AM on March 8, 2007

Personal opinion: if the person in a coma is brain dead, then right away is the time to pull the plug. The family need a funeral and the hospital needs the bed for living patients.

If the person is breathing on their own and "pulling the plug" means withdrawing food and water and starving the person to death: There is no good time to pull the plug, no matter what the prognosis.

All cases in between surely depend heavily on the prognosis of the patient and the wishes of the family.
posted by emilyw at 9:51 AM on March 8, 2007

Don't think anyone will be able to say much specific based on that scant info, but based on personal experience I can at least suggest not asking the doctors to pull the plug -before- tests to verify brain function have even taken place.

And you definitely shouldn't do it front of your entire family. Especially the kids.
posted by Pufferish at 10:01 AM on March 8, 2007

Comas have been known to last for months or years with occasional recovery. Too little information in this case to give advice. Best to discuss the doctors treating the patient, and with other doctors. Very important to discuss with the specialists involved with the case (neurologists, etc), not the critical care doctors overseeing the patent in the ICU, or the internal medicine doctors on the general medical ward. The specialists will generally have much more detailed information regarding the patient's prognosis than the generalists. I am a doctor.
posted by cahlers at 10:05 AM on March 8, 2007

To simply answer your question, no, there is no established time frame.

In case you're dealing with a real situation, I'll offer up a small bit of my experience. If the patient is on a ventilator to help them breathe, it is possible that they are also on some kind of IV sedative to keep them from fighting the vent tube down their throat (yes, patients in comas may still fight the tube - the keep-the-throat-clear instinct is incredibly strong). This sedative can make it impossible to gauge a person's ability to come out of the coma or even breathe on their own, as the medicine is basically helping keep them under. It's almost unbearable to watch someone fight their ventilator tube, but my experience says you need to get them off the sedatives for a significant period of time (hours or days, depending on the specific sedative) before you can make that call.
posted by vytae at 10:10 AM on March 8, 2007

(IANAD but I watched my dad come out of a coma recently, under the circumstances I described. He started to wake up on the day the neurologists had advised us to give up hope - his body just took longer than normal to metabolize the sedatives.)
posted by vytae at 10:15 AM on March 8, 2007

...if the person in a coma is brain dead...

Although the terms are all too often used interchangeably, brain death is not the same as a coma; it is a specific state defined by strict criteria from which there is no possibility of recovery. It is legally equivalent to death in all 50 states. The only time such patients are kept on support in the ICU is for possible organ donation.

Coma, as has been alluded to above, is a broadly defined state of impared consciousness ranging from the brief loss of consciousness following a concussion to a chronic vegetative state similar to brain death but with some retained reflex functions such as breathing. Needless to say, the prognosis and appropriate care for patients varies greatly depending where on this spectrum they fall.
posted by TedW at 10:36 AM on March 8, 2007

If the person is breathing on their own and "pulling the plug" means withdrawing food and water and starving the person to death: There is no good time to pull the plug, no matter what the prognosis.

I'm not sure I agree with this -- artificial nutrition and hydration really depends upon the person's and the family's goals. There are studies that show that people who are near death are more comfortable when they are not given hydration and nutrition -- the body is shutting down, and not taking in water and food is part of that natural process. My brother chose not to have hydration and nutrition at the end of his life, and we respected that choice. There was no evidence of any discomfort.

(And I say this even though I might choose for myself artificial nutrition and hydration if I ever get around to filling out a living will -- because I might prefer the extension of (some) life over the natural process.)
posted by ClaudiaCenter at 10:37 AM on March 8, 2007

I've recently read some information on doctors who have performed MRI scans on coma patients, and then "told" those patients to imagine running or to imagine being in pain.. and the MRI scan has shown the relevant parts of the brain activating. Coma is complex, and what makes it really hard is that there might be a person totally alive and mentally screaming their lungs out in there.
posted by wackybrit at 11:06 AM on March 8, 2007

Is there some established ethical time frame?

No. You don't have to go back and read all the Schiavo commentary to understand that this subject is a matter of debate among ethicists, religions, politicians, the public, families and individuals.

Ask a general and non-specific question, get a general and non-specific answer...
posted by Robert Angelo at 1:12 PM on March 8, 2007

After you try giving them some Ambien.
posted by hindmost at 1:24 PM on March 8, 2007

Like vytae, this is my, er, life. Obviously, there is no rule. In addition, there may be no test to be able to tell if the person is brain dead or not.

In my experience: 1) the doctors really want to pull the plug and soon, though they don’t really know any more than you. If possible put them off for at least two weeks. Be firm. 2) the less power you have the worse care you are going to get. Someone in a coma is a huge pain in the ass for the staff to take care of right and if the person is going to live they are almost certainly going to need a serious advocate. Its close to a full time job.

If this question pertains to your current situation, my sympathies. You had better start taking care of yourself. You thought your were in for a sprint but it is more likely a marathon.
posted by shothotbot at 1:49 PM on March 8, 2007

It could be longer than you might think.
posted by oaf at 2:55 PM on March 8, 2007

Having been through this situation, first off, if you are in it, my deepest, most profound sympathies. Unless you have lived through it, you can't know exactly how incredibly painful it is. (I have grown to hate the term "pulling the plug")

You can't possibly know, nor can the doctors when the right time is to remove life support. There is no time line. None. You have only the information available to you at that time and you make that decision then. You will be torn between your love of the individual and our own humanistic ingrained optimism with the reality of the nightmare for the decision to be made.

Once that decision is made, there is usually no turning back. None. There is no more sobering experience to realize that the nurse is not coming by to fluff his pillow to make him more comfortable because well...

Sorry. Some personal baggage there.

The point is, that to make a decision based on arbitrary timings is fruitless. It is a medical decision based upon the real chances of survivability of the patient's physical condition, their age, and a reasonable prognosis for recovery. Your doctor is best to advise you on this and you must make this decision as a family if no living will exists. However, shothotbot also has it right. You also need to take care of yourself.

Again, I pray you are not in this situation.
posted by fox_terrier_guy at 5:04 PM on March 8, 2007