End - of - life decision making concerning patients with disorders of consciousness

Chronic disorders of consciousness Chronic disorders of consciousness (CDC) are states of illness that are notorious for provoking substantial ethical quandaries. The fiction literature, cinema and theater abound with stories of individuals who have been lying in coma for months or years until they eventually (and miraculously) wake up to see a world that has significantly changed. Famous examples are Pedro Almodóvars Habla con Ella, Wolfgang Beckers Goodbye Lenin or Alex Garlands The Coma. Coma is a borderline state of human existence. The word " coma " originates in ancient Greek where it means " deep sleep ". In medicine, it has come to signify a state of deep unconsciousness, where a person cannot even be awakened by intensive stimuli like pain. 1 Usually, coma is a transient state after an accident, in the crisis of a grave disease or, artificially provoked, in narcosis during surgery. A non-artificial coma usually lasts for up to three weeks until the patient either recovers and slowly regains consciousness or deteriorates and dies. Recovery can, however, come to a standstill at a very basic level of brain functioning. This is the level of the so-called vegetative state (VS), in which the functions of the evolutionarily ancient brainstem are intact, but the evolutionary younger and more vulnerable cerebral cortex lacks regular function. 2 These patients (their state is also called apallic syndrome, wakefulness coma or coma vigile) show sleep-wake cycles with open eyes during daytime, reflex motor activity, spontaneous breathing and integration of vegetative bodily functions like the hormone system, blood pressure and body temperature. They do not display, however, any intentional behavior, any consistent responses to stimuli or any purposeful interaction with the environment.