In the Blink of the Mind’s Eye

Abstract

Imagine rushing to the hospital because your loved one has had a serious brain injury or cardiac arrest. The doctors tell you that the patient is unconscious and will not recover. Still reeling from the sudden news, you are asked about any end-of-life care preferences and whether you will agree to a do-not-resuscitate order. You and your loved one had some conversations about death and dying and signed advance directives after the Schiavo affair, but in retrospect, it all seems incredibly superficial and provides little guidance. It is such a lonely moment--asked such things by doctors you don't know or trust. The one person who could guide you is lying in the bed before you on a breathing machine. If only you could ask ... Now imagine rolling your loved one down to the hospital's MRI machine and asking him if he wants to live or die by reading his responses on the scanner. This is still the stuff of science fiction, but researchers from the Universities of Cambridge and Liege just reported in the New England Journal of Medicine how functional magnetic resonance imaging, or fMRI, might someday be used as a communication tool for patients with disordered conscious, in the vegetative and minimally conscious states. They studied fMRI brain activations seen when patients were asked to imagine tasks like hitting a tennis ball or seeing the rooms in their home. Patients were asked to use one of these responses for yes and the other for no. The images demonstrated an especially profound discordance between what was seen on clinical exam and what was indicated by neuroimaging for one patient, previously deemed vegetative, who could communicate. This technology does more than open up the possibility of communicating with people thought to be unconscious and unreachable. It also suggests that neuroimaging must eventually be integrated into the clinical assessment of many patients who are vegetative or minimally conscious. This is a dramatic finding and a potential game-changer for clinical practice. But it is not so simple. Only five of fifty-four patients studied demonstrated the ability to follow researchers' commands, and all of these had traumatic brain injury. And, paradoxically, some patients with higher levels of cognitive function--similar to the locked-in patient Jean Claude Bauby, who authored The Diving Bell and the Butterfly by blinking his left eye--might not be able to communicate using this fMRI paradigm. Scientifically, it is important that we further understand the variance in measured responses. Only then will this technology become a reliable resource to assess the presence or absence of consciousness and one's ability to communicate. But, for the few patients for whom it might work, can a signal on an MRI scan help guide decisions about end-of-life care? Might these responses reach the clinical standard of decision-making capacity or legal competence? Can patients show enough understanding for the rest of us to appreciate that their choices reflect authentic patient self-determination? Certainly, this is not yet the case, nor will it be anytime soon. As a proxy for discussion with the patient, this mind-brain interface may be inferential and misconstrued. After all, even when we are simply talking with each other, miscommunication can occur. The pitfalls of reading too much into this technology become apparent if we recall the 2001 Wendland case from California. Robert Wendland recovered to a minimally conscious state several months after a motor vehicle accident. His wife, Rose, consented to routine medical care, including the replacement of several dislodged feeding tubes, until physicians sought her authorization for a fourth insertion. She refused after consultation with her children and Robert's brother, all of whom felt that Mr. Wendland would not have wanted the intervention. Mr. Wendland's doctors agreed, as did all members of the hospital's twenty-member ethics committee. …