scholarly journals Why futile and unwanted life-prolonging treatment continues for some patients in permanent vegetative states (and what to do about it): Case study, context and policy recommendations

2018 ◽  
Vol 2017 (24) ◽  
pp. 129
Author(s):  
Jenny Kitzinger ◽  
Celia Kitzinger
Keyword(s):  
Vegetative State ◽  
Best Interests ◽  
Policy And Practice ◽  
England And Wales ◽  
Brain Injured ◽  
Life Sustaining Treatment ◽  
Nutrition And Hydration ◽  
Study Context ◽  
Injured Patients

In August 2017 a judge sanctioned withdrawal of clinically assisted nutrition and hydration from a patient who had been sustained in a vegetative state for twenty-three years, finding it “overwhelmingly in his best interests” for treatment to stop, allowing him to die. Injured in 1994, this patient had continued to receive life-sustaining treatment long after clinicians, and his family, had abandoned any hope for recovery and with no evidence that he would have wanted to be kept alive this way. Based on interviews with his parents, and the court hearing, we explore how it came about that he received this treatment for so long. We contextualize this in relation to our wider research about the treatment of severely brain injured patients and ask why, despite guidelines, policies and statute concerning best interests decision-making, thousands of patients in permanent vegetative states are similarly maintained in England and Wales without any formal review of whether continuing clinically assisted nutrition and hydration is in their best interests. We consider the implications for ethics, policy and practice in relation to patients with prolonged disorders of consciousness more broadly, highlighting in particular the actions that need to be taken by clinicians, inspection bodies, Clinical Commissioning Groups and Health Boards across England and Wales.

‘It’s all considered to be unacceptable behaviour’

2016 ◽  
Vol 63 (4) ◽  
pp. 433-451 ◽  
Author(s):  
Vickie Cooper
Keyword(s):  
Criminal Justice ◽  
Housing Policy ◽  
Local Authority ◽  
Housing Authority ◽  
Policy And Practice ◽  
England And Wales ◽  
Critical Questions ◽  
Housing Options ◽  
Criminal Justice Practitioners

Despite a growing recognition of the intersectional relationship between homelessness and incarceration, we have a limited knowledge about housing policy and practice for people leaving custody and (ex)offender groups in the community. Addressing these gaps, this paper provides an overview of the main local housing authority statutory duties in the provision of housing support for prison leavers and (ex)offenders in England and Wales, and situates the issues with accessing accommodation within the wider context of austerity. The paper presents a case study that explores criminal justice practitioners’ experiences of working with local authority housing agencies. Stemming from 25 interviews with housing practitioners and criminal justice practitioners, the paper outlines the main challenges facing criminal justice agencies as they try to secure accommodation for homeless (ex)offenders and resettle them in the community. Finally, the paper concludes by raising critical questions about the housing options for this population, now and in the future.

Understanding the privatisation of probation through the lens of Bourdieu’s field theory

2020 ◽  
pp. 59-74
Author(s):  
Jake Phillips
Keyword(s):  
Field Theory ◽  
Criminal Justice ◽  
Symbolic Violence ◽  
Policy And Practice ◽  
England And Wales ◽  
Growing Body ◽  
Probation Service ◽  
Rehabilitation Needs ◽  
The Way

This chapter contributes to the growing body of criminological work to use Bourdieu’s field theory to understand changes in policy and practice in criminal justice. The chapter uses the privatisation of probation services in England and Wales as a case study to argue that although probation practitioners vociferously opposed the reforms, their attempts to prevent them were always unlikely to succeed. This is because Transforming Rehabilitation needs to be understood as the culmination of a longstanding process of symbolic violence which resulted in the depreciation of relevant forms of capital amongst practitioners and their allies. The chapter begins with a brief overview of the reforms before turning to a discussion of Bourdieu’s field theory. I argue that because ‘capital’ links field and habitus – in that capital is the product of the way in which habitus and field are, or are not, attuned to one another – this is an important mechanism of field theory which has, hitherto, been neglected. I argue that as probation practitioners’ habitus has remained relatively stable over the last fifty years, the changing field led to a delegitimation of the forms of capital owned by practitioners which left them unable to mount a successful defence of a public probation service.

scholarly journals Judicial oversight of life-ending withdrawal of assisted nutrition and hydration in disorders of consciousness in the United Kingdom: A matter of life and death

2017 ◽  
Vol 85 (3) ◽  
pp. 148-154 ◽  
Author(s):  
Mohamed Y Rady ◽  
Joseph L. Verheijde
Keyword(s):  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Disabled Persons ◽  
Disorders Of Consciousness ◽  
Best Interests ◽  
Life And Death ◽  
Decision Making Capacity ◽  
Nutrition And Hydration ◽  
Minimally Conscious

Mr Justice Baker delivered the Oxford Shrieval Lecture ‘A Matter of Life and Death’ on 11 October 2016. The lecture created public controversies about who can authorise withdrawal of assisted nutrition and hydration (ANH) in disorders of consciousness (DOC). The law requires court permission in ‘best interests’ decisions before ANH withdrawal only in permanent vegetative state and minimally conscious state. Some clinicians favour abandoning the need for court approval on the basis that clinicians are already empowered to withdraw ANH in other common conditions of DOC (e.g. coma, neurological disorders, etc.) based on their best interests assessment without court oversight. We set out a rationale in support of court oversight of best interests decisions in ANH withdrawal intended to end life in any person with DOC (who will lack relevant decision-making capacity). This ensures the safety of the general public and the protection of vulnerable disabled persons in society.

Principles of Neurologic Ethics

2015 ◽  
Author(s):  
Thomas I. Cochrane
Keyword(s):  
Decision Making ◽  
Informed Consent ◽  
Brain Death ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Best Interests ◽  
Neurologic Disease ◽  
The Face ◽  
Life Sustaining Treatment ◽  
Prognostic Uncertainty

Many neurologic diseases affect the brain and thus cognition and personality. Many people consider some neurologic conditions “worse than death” and would prefer not to be kept alive using medical technology if there is no reasonable chance of recovery. The clinician caring for patients with neurologic disease will frequently be confronted with decisions about whether to initiate or continue life-sustaining therapies. And because neurologic disease often impairs the ability to understand and to decide, clinicians are more often called on to make decisions for patients who cannot decide for themselves. This chapter covers general principles, including respect for autonomy, beneficence, nonmaleficence, justice, informed consent, and implied consent. Discussion about making decisions for others includes competence and decision-making capacity, advance directives (powers of attorney and living wills), substituted judgment, and best interests. Decisions about life-sustaining treatment include withholding versus withdrawing, acts versus omissions, and limiting life-sustaining treatment for the patient with no surrogate. Also covered are decisions in the face of prognostic uncertainty, and futility, as well as commonly encountered problems such as states of severely disordered consciousness, coma, vegetative state, minimally conscious state, and brain death (including ethical controversies). Organ donation after both brain death and cardiac death is discussed. The section on dementia covers feeding tubes for patients with advanced dementia, the locked-in state, and neuroenhancement. Tables include elements of informed consent, elements of competence, assumed ethical priority of potential surrogates, steps that aid decision making in the face of prognostic uncertainty, and the American Academy of Neurology’s criteria for determination of brain death. This chapter includes 23 references.

From Awareness to Prognosis: Ethical Implications of Uncovering Hidden Awareness in Behaviorally Nonresponsive Patients

2019 ◽  
Vol 28 (04) ◽  
pp. 616-631 ◽  
Author(s):  
MACKENZIE GRAHAM ◽  
EUGENE WALLACE ◽  
COLIN DOHERTY ◽  
ALISON MCCANN ◽  
LORINA NACI
Keyword(s):  
Prognostic Value ◽  
Functional Neuroimaging ◽  
Prognostic Indicators ◽  
Severe Brain Injury ◽  
Ethical Implications ◽  
Highly Sensitive ◽  
Brain Injured ◽  
Life Sustaining Treatment ◽  
Injured Patients

Abstract:Long-term patient outcomes after severe brain injury are highly variable, and reliable prognostic indicators are urgently needed to guide treatment decisions. Functional neuroimaging is a highly sensitive method of uncovering covert cognition and awareness in patients with prolonged disorders of consciousness, and there has been increased interest in using it as a research tool in acutely brain injured patients. When covert awareness is detected in a research context, this may impact surrogate decisionmaking—including decisions about life-sustaining treatment—even though the prognostic value of covert consciousness is currently unknown. This paper provides guidance to clinicians and families in incorporating individual research results of unknown prognostic value into surrogate decisionmaking, focusing on three potential issues: (1) Surrogate decisionmakers may misinterpret results; (2) Results may create false hope about the prospects of recovery; (3) There may be disagreement about the meaningfulness or relevance of results, and appropriateness of continued care.

It is never lawful or ethical to withdraw life-sustaining treatment from patients with prolonged disorders of consciousness

2019 ◽  
Vol 45 (4) ◽  
pp. 265-270 ◽  
Author(s):  
Charles Foster
Keyword(s):  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Best Interests ◽  
Legal Analysis ◽  
Best Interest ◽  
Degree Of Certainty ◽  
Life Sustaining Treatment ◽  
Medical Fact ◽  
Minimally Conscious

In English law there is a strong (though rebuttable) presumption that life should be maintained. This article contends that this presumption means that it is always unlawful to withdraw life-sustaining treatment from patients in permanent vegetative state (PVS) and minimally conscious state (MCS), and that the reasons for this being the correct legal analysis mean also that such withdrawal will always be ethically unacceptable. There are two reasons for this conclusion. First, the medical uncertainties inherent in the definition and diagnosis of PVS/MCS are such that, as a matter of medical fact, it can never be established, with the degree of certainty necessary to rebut the presumption, that it is not in the patient’s best interest to remain alive. And second (and more controversially and repercussively), that even if permanent unconsciousness can be unequivocally demonstrated, the presumption is not rebutted. This is because there is plainly more to human existence than consciousness (or consciousness the markers of which can ever be demonstrated by medical investigations). It can never be said that the identity of the patient whose best interests are at stake evaporates (so eliminating the legal or ethical subject) when that person ceases to be conscious. Nor can it be said that the best interests of an unconscious person do not mandate continued biological existence. We simply cannot know. That uncertainty is legally conclusive, and (subject to resource allocation questions and views about the relevance of family wishes and the previously expressed wishes of the patient) should be ethically conclusive.

scholarly journals Selegiline in Patients With Disorder of Consciousness: An Open Pilot Study

2018 ◽  
Vol 45 (6) ◽  
pp. 688-691
Author(s):  
Orsola Masotta ◽  
Luigi Trojano ◽  
Vincenzo Loreto ◽  
Pasquale Moretta ◽  
Anna Estraneo
Keyword(s):  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Clinical Effects ◽  
Disorder Of Consciousness ◽  
Brain Injured ◽  
Minimally Conscious ◽  
Injured Patients ◽  
Open Pilot

AbstractThis open study investigated the clinical effects of 10-week selegiline administration in six patients in vegetative state and in four patients in a minimally conscious state, at least 6 months after onset. Clinical outcome was assessed by Coma Recovery Scale-Revised once a week during selegiline administration and 1 month later. Three patients stopped treatment because of possible side effects. After treatment and at 1 month of follow-up, four patients showed improvements in clinical diagnosis, and three patients showed an increase in arousal level only. Selegiline might represent a relatively safe option to enhance arousal and promote recovery in brain-injured patients with disorders of consciousness.

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