Consciousness and controversy

Medical advances in the 1950s and ’60s gave rise to the debate over when to withdraw life-sustaining care. Despite breakthroughs in scientific knowledge over the past 20 years, medical care and end-of-life decisions are still shaped, in large part, by a primitive understanding of brain injuries and consciousness.

1972

Bryan Jennett, a British neurosurgeon, and Fred Plum, an American neurologist, coin the term “persistent vegetative state” in a landmark paper published in The Lancet, describing such patients as “incapable of communication and without hope of recovery as social human beings.”

1976

In a landmark case, the New Jersey Supreme Court orders a hospital to honor the request of Karen Ann Quinlan’s parents to remove her ventilator. Doctors had determined the woman was in a vegetative state. The court rules that keeping her alive would be “cruel and unusual.”

1990

In the first right-to-die case to reach the U.S. Supreme Court, justices rule 5-4 that the parents of Nancy Cruzan of Missouri needed to present “clear and convincing evidence,” such as a living will, that their daughter wouldn’t want to live in a vegetative state before they could direct the hospital to remove her feeding tube. The case established that the right to die was not guaranteed by the Constitution, and it set out guidelines for what was required for a third party to refuse treatment on behalf of a loved one.

1994

Research finds that, of those in a vegetative state one month after a traumatic brain injury, more than 50 percent regain consciousness after one year. The finding prompts the American Neurological Association to issue guidelines eliminating the use of the term “permanent” in assessing patients believed to be unconscious following brain injury.

2001

In one of the first legal cases involving an endof-life decision for a “minimally conscious” patient — a year before that term was officially established — the California Supreme Court rules that the wife of Robert

Wendland have remove the his authority does feeding not to tube. Though the court holds that a family member can withhold artificial nutrition and hydration from a patient in a vegetative state, the justices view that as quite different from when a patient is conscious but incompetent because such a patient might perceive the effects of starvation and dehydration.

2002

A task force of leading neurologists and rehab physicians releases a report defining, for the first time, the state of heightened awareness that many vegetative patients seem to emerge into, dubbing it “the minimally conscious state.”

2005

A federal court orders a hospital to remove Terri Schiavo’s feeding tube, ending a decadelong legal battle and one of the nation’s most famous end-oflife controversies involving a vegetative patient. The case swung public sentiment in support of “death with dignity” and led to a surge in the number of people signing living wills to direct physicians and loved ones when to withdraw medical care after an accident.

2009

A study of patients in nursing homes finds that 41 percent of those with vegetative state diagnoses are, in fact, minimally conscious, confirming previous reports of high misdiagnosis rates and raising concerns that thousands of conscious patients had been denied an opportunity for rehabiltation. Sources: L. Syd M. Johnson, Michigan Technical University; National Center for Biotechnology Information

Associated Press file In May 2001, Robert Wendland lies in a Lodi, Calif., hospital, where he’d been since a car accident seven years before. He died that July of pneumonia.

Quinlan

Reuters file The bitter legal case of Terri Schiavo, shown with her mother, Mary Schindler, captured the nation’s attention. Schiavo’s brain had been deprived of oxygen after a heart attack in 1990.