Owen signs of improved consciousness, precisely through

Owen et al. (2006) describe VS as being one of the least understood and morally contentious areas within modern medicine. To adequately diagnose and treat those with a DoC physicians must be able to differentiate between a VS and an MCS. However, the spectrum of physical activity and awareness within these patients is extremely heterogeneous with no discernible scientific method of proper diagnosis (Andrews et al. 1996). To determine the difference between VS  and MCS, the ability to show consciousness remains at the heart of diagnosis (Farah 2008). Currently, medical professionals diagnose patients as vegetative if they are no longer able to respond meaningfully or purposefully to a command, thus displaying a lack consciousness (Monti, Coleman and Owen, 2009). This method is highly subjective as it requires the physician to interpret behaviour which may differ from clinician to clinician. Andrews et al. ( 1996)  showed this behavioural diagnosis method to have a 40 % misdiagnosis rate (in which medical practitioners inaccurately describe minimally conscious patients as vegetative). Misdiagnosis has implications on caretaking, and ethical considerations as proper recognition of consciousness allows for better quality of care and prevents discontinuing or continuing life against the patient’s wishes (Farisco and Petrini 2014). Additionally, under US legislature patients who demonstrate some level of consciousness (MCS) may move “from the ‘possibly allowed to die’ category to the ‘not allowed to die’ category”(Cyranoski 2012). Therefore definite diagnosis is not only crucial for treatment but also for patients end of life choices.One such case is the misdiagnosis of Terry Wallis. After 19 years of being in a VS, Terry Wallis showed signs of improved consciousness, precisely through the ability to speak. Once the medical case was reviewed, it emerged that there was a shift from VS to MCS over the many years but this was not noticed by his primary care providers (Wijdicks, 2006). The case of Terry Wallis further highlights the difficulties in differing between types DoC.  To better differentiate VS and MCS  Zheng et al. (2016) conducted a study looking at differences in thalamocortical connections of  DoC patients. Zheng et al. (2006) concluded that MCS patients exhibited more thalamocortical connections, compared with VS, allowing for a discernible neurobiological marker that can aid in proper diagnosis. This cannot be implemented in living patients as it requires a brain sample, but it is an advancement in the direction of more concrete diagnostic tools and does provide evidence that there are apparent differences between types of DoC. Accurate diagnoses are acutely essential to families and the individual themselves, who can then consider whether to forego end-of-life procedures based on this decision.Before analysing whether patients in a VS can make informed decisions concerning the end of life choices, the current policies regarding end of life for DoC patients must be examined.  Current medical practice for DoC patients is determined by balancing the risk and benefits of life-sustaining treatment. When considering withdrawing therapeutic interventions, the desired outcome of the patient is the primary concern. For example, providing life-sustaining treatment may prolong dying, increase suffering, and be in opposition to the patient’s wishes  (Fisher and Ridley 2012).  An extensive European study with medical professionals found that 82% of participants would not want to continue life-sustaining treatment if in a VS, which may reflect the current societal outlook on VS patients as being clinically unaware (Demertzi et al. 2011).  In 2013 the Hastings Center Bioethics Research Institute updated their 1987 guidelines regarding the end of life care for vegetative patients to clarify an accepted approach. The guidelines aimed to focus on a patient’s right to refuse medical intervention and further specified following the patient’s wishes when known as seen through the use of advanced directives. If their requests were not known, then the surrogate decision-making process was relied upon using the patient’s values and preferences to decide when the patient no longer has decision making capability (Lustbader 2013). Further complicating the end of life process are the different clinical steps when approaching an MCS patient as compared to  VS patient. MCS patients are considered to have a higher awareness and therefore are given greater moral status (Lawrence et al. 1999). US courts have concluded that unless there is an advanced directive stating the ending of life wishes, then life-preserving care must be provided to MCS patients (Buckley et al. 2004). The current medical approach to the end of life choice reflects the societal view that patients in VS are considered to have lower ethical value than MCS patients. This has an impact on whether life-sustaining treatment can be withdrawn or imposed. Thus, VS patients have been efficiently marginalised by the medical community (Fins 2015)  but emerging neuroimaging studies suggest patients previously thought to be unconscious

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