CATASTROPHIC NEUROLOGICAL INJURY. Supplemental
nutrition is commonly provided in patients in the neurological
intensive care unit, be it patients with stroke or head
trauma with brain injury. Most such patients have altered
consciousness and are unable to eat. Some stroke patients
will have dysphagia as a manifestation of neurological injury,
although many will eventually recover swallowing function.
In the initial assessment of these patients, outcome cannot
always be defined. Moreover, in young patients with head
trauma, for example, families cannot easily accept the prospect
of death or at best, permanent loss of cognitive function
requiring indefinite custodial care. It is thus reasonable to
implement artificial nutritional support during the acute
care of patients with severe neurological injury. With failure
of recovery, however, the decisions regarding long-term
support, including enteral casino tube feedings, must at some point
be confronted. At the very least, any benefits and adverse
effects of continued support become items of discussion.
Devastating neurological injury from trauma or
nontraumatic etiology (e.g., hypoxic encephalopathy, extensive
cerebral hemorrhage or infarction) are a common cause
of permanent vegetative state (PVS) in which patients may
exhibit wakefulness but otherwise have no detectable awareness.
These patients have been casino particularly visible in the
public eye because of the Karen Ann Quinlan and Nancy
Cruzan cases in which the courts have also played a role.
There are no trials of enteral tube feedings in patients
with PVS. This disorder is different from advanced dementia,
and terminal cancer in which supplemental nutrition is
considered as an adjunct to management in dying patients
but does not affect outcome. In PVS, it is clearly life
sustaining treatment: Brain injury, this devastating, is lethal
and it is only with artificial provision of nutrition and fluids,
and in some cases other supportive interventions, that these
patients continue to live. The mechanics of providing nutrition
differ little, however, and because feeding may be
indefinite, PEG is the route most often chosen.
