The LockedIn Syndrome and the Minimally Conscious State

Brain death and the vegetative state should be contrasted with two other contemporary neurological syndromes of severe brain damage: the locked-in syndrome and the minimally conscious state. The locked-in syndrome, first named by Fred Plum and Jerome Posner in 1966, is characterized by a severe paralysis of the entire body, including the extremities and facial muscles, but with normal or nearly normal consciousness. This often results from a severe stroke to the brainstem that spares the cerebral hemispheres (in one sense the reverse of the vegetative state), and these patients often appear to be unconscious; however, a careful history and neurological examination uncover a high degree of cognitive functioning. Some physicians use this term to denote patients with any degree (e.g., mild to moderate) of disparity between paralysis and cognitive functioning. However, this term, when used properly, means a profound disparity between paralysis (severe) and consciousness (normal or nearly normal).

Unlike brain death, the vegetative state, and the locked-in syndrome, all of which are fairly well characterized and accepted by the medical profession, the term minimally conscious state is of relatively recent vintage, and its acceptance and potential usefulness as a distinct neurological syndrome are far from settled. Formally called the minimally responsive state, the minimally conscious state is defined as a condition of "severely altered consciousness in which minimal but definite behavioral evidence of self or environmental awareness is demonstrated," in other words, a condition of severely to profoundly impaired cognitive functioning (Giacino et al.). This diagnosis is made by the demonstration on a reproducible or sustained basis of one or more of the following behaviors: following simple commands, gestural or verbal yes/no responses, intelligible verbalization, and purposeful behavior such as appropriate smiling or crying, pursuit eye movement, and sustained visual fixation. Even though the difference between being vegetative and thus completely unconscious and being "minimally" conscious may seem to be a subtle distinction and even though some have argued that being minimally conscious is a medical fate worse than being vegetative, the courts in recent landmark decisions and many healthcare professionals have treated these syndromes radically differently from a medical, ethical, and legal standpoint (Rich).

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