A PVS Patient on Dialysis

Mr. W., a 55-year-old African American, had been standing on a street corner when he suddenly fell to the pavement tearing open his nose. No one witnessed the episode so it was not clear if he had experienced a grand mal seizure. Mr. W. was taken to the county hospital emergency department where his nose was sewn and reattached. His private physician, who had cared for Mr. W. for 10 years, was contacted and informed of his patient's situation and asked if he thought it would be reasonable for the patient to be discharged. The private physician said, "No"; he thought Mr. W. should remain under observation for the next 24 hours because he had a number of problems, including sickle cell thalassemia, chronic renal failure that required dialysis twice a week, and a history of grand mal seizures for which he was receiving antiepileptic medication. There had been at least one documented episode of tachy-brady arrhythmia. Shortly after the telephone conversation with his private physician. Mr. W. suffered a grand mal seizure and was given proper anticonvulsant medications. The seizure subsided, and Mr. W. was put in a bed in the emergency department for observation for the postictal state. About 1 hour later Mr. W. was observed to be breathing irregularly and it was noted that his heart rate had fallen to 30 beats per minute and his peripheral pulses were absent. Resuscitation was begun. He was intubated with an endotracheal tube and put on a respirator. He was admitted to the hospital, where he remained unconscious. He was seen by a neurologist who found that he was unconscious and unresponsive to commands. He did have some brain stem activity, including spontaneous respirations. The neurologist saw Mr. W. a number of times and concluded that he was in, or approaching, a persistent vegetative state (PVS). He was dialyzed and given all of the care that one could provide for this man given his multiple diagnoses, including antiarrhythmic medications and anticonvulsants. On approximately the 10th or 11th day, the physicians at the county hospital told Mrs. W. that her husband was permanently unconscious in a PVS and they thought the dialysis should be stopped and medical care gradually withdrawn. Mrs. W. was reluctant to follow these recommendations and wanted the patient to be under the care of his private physician who had been caring for his multiple problems over the last decade. The private physician was contacted and he agreed to assume the patient's care if he were transferred to the community hospital where he practiced. Upon arrival at the community hospital, the patient was noticed to be making respiratory efforts on his own and his physician recommended that the endotracheal tube be removed after an appropriate trial of spontaneous breathing through the tube. Mrs. W. agreed, and her husband was extubated. She also agreed to a do-not-resuscitate (DNR) order should cardiac arrest occur.