Neuroethics with regard to treatment limiting and withdrawal of nutrition and hydration in long lasting irreversible full state apallic syndrome and minimal conscious state.

INTRODUCTION

Epidemiology in Europe shows constantly increasing figures for the Apallic Syndrome (AS)/Vegetative State (VS) as a consequence of advanced rescue, emergency services, intensive care treatment after acute brain damage, and high standard activating home nursing for completely dependent end stage cases secondary to progressive neurological disease. Management of patients in irreversible apallic syndrome has been the subject of sustained scientific and moral-legal debate over the last decade.

METHODS

Neuroethics coming more and more into consideration when neurological societies address key issues relating to AS/VS prevalence and quality management. With regard to treatment limiting and withdrawal of nutrition and hydration of patients suffering from irreversible full state Apallic Syndrome and Minimal Conscious State.

RESULTS

The overall incidence of new AS/VS full stage cases all aetiology is 0.5 - 2/ 100.000 population per year. About one third is traumatic and two thirds are non-traumatic cases. The worst prognosis might be expected from nontraumatic hypoxemic apallic syndrome. The main conceptual criticism is based on assessment and diagnosis of all different AS/VS stages based solely on behavioural findings without knowing the exact or uniform pathogenesis or neuropathologic findings. No special diagnostics, no specific medical management can be recommended for class II or III AS treatment and rehabilitation. But in United Kingdom, The Netherlands, Belgium, and Switzerland active euthanasia is now practiced in medicine taking into account the uncertainty of the right diagnose the clinical features for humanistic treatment of patients in irreversible "AS full or early, remission stages".

DISCUSSION

As long as there is no single AS/VS specific diagnostic tool, no specific laboratory investigation regimen to be recommended neuroethical principles demands by all means a humanistic (ethical) activating nursing even in the irreversible full stage AS cases. Full acceptable is only the palliative pain therapy with renunciation of maximal therapy. Active euthanasia is a criminal act and has to be respected as such in neuroscience.