Spittler J F
Neurologische Universitätsklinik, Knappschafts-Krankenhaus, Bochum-Langendreer.
Fortschr Neurol Psychiatr. 1999 Jan;67(1):37-47. doi: 10.1055/s-2007-993736.
During the past few years there is an ethical debate about neurological disease entities that are characterised by a) prolongation of life owing to medical treatment, b) limited chances of cure, and c) impaired to unbearable life quality: akinetic mutism, vegetative state ("Wachkoma", apallic syndrome), and locked-in syndrome. These are compared to typical coma and brain death. According to Gerstenbrand (1967) [34] the vegetative state is differentiated into the transitional state following typical coma, the variations of typical and incomplete vegetative state, the remission state and the "Durchgangssyndrom" (characterized by preserved wakefulness with affective lability, disorientation, and amnesia). With regard to pathogenesis we differentiate posttraumatic and posthypoxic origin and variable lesions in cerebral cortex, thalamus or mesencephalic reticular formation. Uncertainty of prognosis is stressed. In respect of brain death we compare a) neocortical death, b) brain stem death, and c) whole brain death, and discuss problems of difficult delimitation and uncertainty of diagnosis. These syndromes are compared to anencephaly and hydranencephaly. Regarding the locked-in syndrome, typical, incomplete and complete (total) forms are distinguished. The differential diagnosis between the complete locked-in syndrome and brain stem death seems problematic. Difficulties in decisions limiting therapeutic effort stem from a) essentially intuitive judgement about observations, b) variability of syndromes and courses, c) uncertainty of prognosis, and d) differences in understanding and valuation throughout society. Emphasis is on a trustful and open colloquy among the persons concerned.
在过去几年里，针对一些神经疾病实体存在一场伦理辩论，这些疾病实体的特征为：a) 因医疗手段而延长生命；b) 治愈机会有限；c) 生活质量受损至无法忍受的程度，即运动不能性缄默症、植物状态（“睁眼昏迷”，去大脑皮质综合征）和闭锁综合征。将这些与典型昏迷和脑死亡进行了比较。根据格尔斯滕布兰德（1967年）[34]的研究，植物状态可分为典型昏迷后的过渡状态、典型和不完全植物状态的变体、缓解状态以及“通过综合征”（其特征为保持清醒但伴有情感不稳定、定向障碍和失忆）。关于发病机制，我们区分创伤后和缺氧后起源以及大脑皮质、丘脑或中脑网状结构的不同病变。强调了预后的不确定性。关于脑死亡，我们比较了a) 新皮质死亡、b) 脑干死亡和c) 全脑死亡，并讨论了难以界定和诊断不确定的问题。将这些综合征与无脑畸形和积水性无脑畸形进行了比较。关于闭锁综合征，区分了典型、不完全和完全（总计）形式。完全闭锁综合征与脑干死亡之间的鉴别诊断似乎存在问题。限制治疗努力的决策困难源于：a) 对观察结果基本上是直观的判断；b) 综合征和病程的变异性；c) 预后的不确定性；d) 整个社会在理解和评估方面的差异。重点在于相关人员之间进行信任和开放的对话。
