지속적 식물상태에 대한 고찰

이인수 대한신경외과학회 1991 Journal of Korean neurosurgical society Vol.20 No.5

Patients with overwhelming demage to the cerebral hemispheres commonly pass into a chronic state of unconsciousness(ie, loss of self awareness) called the vegetative state. When such cognitive loss lasts for more then a few weeks, the condition has been termed a persistent vegetative state. The auther reviewed "Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state patient" adopted by the Executive Board. American Academy of Neurology. April 21. 1988 and "Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association" -1989. In the U.S.A they insist "If the patient is competent to act in his own behalf and did not previously indicate his preferences, the family or other surrogate decision maker, in concert with the physician, must act in the best interest of the patient" and "Even if death is not imminent but a patient is beyond doubt permanently unconscious, and there are adequate safeguards to confirm the accuracy of the diagnosis, it is not unethical to discontinue all means of life-prolonging medical treatment." In Korea "brain death" has not been referred to the death of the individual yet socially and legally. The neurosurgeons in our country must consider about how seriously to treat vegetative patients and brain death patients who are unlikely to improve, in the concerns of bio-medical ethice. On the other hand, they recognize that their capacity to achieve a diagnosis and highly probable prognosis represents the indispensable basis for any decision. This article provides criteria for the diagnosis of persistent vegetative state and reviews the available data of my 19 patients. Lastly in our country any considerations or discussions have not yet been made with regard to withdrawal of life support to patients in persistent vegetative states according to the national emotion and morality.

식물인간이 된 성인자녀를 돌보는 어머니의 체험

양영미,김증임 한국여성건강간호학회 2017 여성건강간호학회지 Vol.23 No.4

Purpose: The purpose of this study was to deepen understanding the nature of the care experience by the mothers with adult children in persistent vegetative state. Methods: Participants were 7 mothers caring for their adult children in persistent vegetative state. Data were collected individually through in-depth interviews on their lived experiences. Also texts were included as data from literary works, novels, movies, essays, and arts containing on patients with persistent vegetative state and their mothers. Data were analyzed by van Manen’s phenomenological methodology. Results: The essential themes of caring experiences of the mothers were as follows. The theme in relation to lived time has shown as back to the past and caring experience related lived body has emerged as locked the body in children. The theme related lived space was getting into the swamp and the theme in lived others was derived as lonely struggle into. Conclusion: The nature of mothers’ caring experiences for adult children in persistent vegetative state is summarized as ‘Do not off hand of hope in a locked state’. This study suggests long-term supports are necessary for mothers to care persistent vegetative state children.

문헌을 통해 추정한 두부외상후 지속적 식물상태의 여명 : Review of Literature and A Proposal

이경석 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.2

Although the life expectancy of posttraumatic persistent vegetative state is obviously expected to be shorter than that of the general population, exact estimates of the length of survival are not avaliable, however. The author, after reviewing literatures on the definition, criteria for diagnosis, and prognosis of the persistent vegetative state, has proposed a table for the estimation of life expectancy of posttraumatic persistent vegetative state. In this proposal, age and sex of the patient as well as the duration of the vegetative state were used as determining factors of lifespan. Although this proposal is not based on the actual data, it still could serve as a helpful reference to estimate the patients life expectancy and minimizing discrepancies among clinicians with different personal experience.

전국 수련병원에 입원중인 지속적 식물 상태환자 현황 및 사회, 경제학적 문제점에 대한 연구 : Fate and Socioeconomic Problem

박상근,권점대,신형식,김상진 인제대학교 1997 仁濟醫學 Vol.18 No.4

사회구조가 복잡하고 인구 구조가 노령화함에 따라 뇌손상과 뇌졸중 환자가 증가하고 있으며, 발전된 의술로 이런 환자들을 적극적으로 치료하여 식물상태 환자는 점차 증가 추세에 있다. 저자는 이와 같은 환자들에 대한 효과적인 관리와 향후 대책 수립에 도움을 주고자 전국 수련병원급 이상의 신경과 및 신경외과에 입원가료하고 있는 식물상태 환자를 설문지 양식에 의거하여 취합하여 그 현황을 보고한다. The term persistent vegetative state(PVS) describes patients without recognizable psychological adaptive response to the environment, associated wish long periods of wakefulness. As resuscitation technique and intensive care technology have improved, an increasing number of comatose patient now survive for prolonged periods, entering a persistent vegetative state. In response to inquiries to 325 training hospitals in Korea, 217 cases were gathered from 77 hospitals, Two major causes of PVS were trauma (50%) and cerebrovascular diseases (37%). In 90% the duration of PVS were less then 3 years. In 54% the medical expenses were paid by without coverage of medical insurance. Most family numbers and physicians have no future plan for those particular patients except 14 % of the patients wanted home care system. With the increasing emphasis on reduction of medical costs, and the expanding role of government to reduce this cost, health care policy for the PVS has aroused much discussion from bosh the medical profession and the public at large.

연명치료중단 법제화의 전제조건에 대한 검토 -세브란스병원사건에 대한 법원 판결의 의미와 시사점-

이상용 ( Sang Yong Lee ) 한국법정책학회 2012 법과 정책연구 Vol.12 No.3

연명치료중단의 문제는 2008년 세브란스병원사건을 계기로 다시 한 번 커다란 사회적 관심의 대상이 되었는데, 이에 대한 법원의 판결에서 연명치료중단의 일정한 기준을 발견할 수 있다는 점에서 관련 논의의 의미 있는 진전을 이루게 되었다고 볼 수 있다. 그러나 일정한 경우 연명치료의 중단이 허용되어야 한다는 데에는 대체로 많은 사회구성원들이 동의하고 있지만, 그 사회적 합의의 구체적 내용에는 불분명한 점들이 여전히 존재한다. 의견이 대립하는 분야는 사전의료지시서의 요건과 효과, 연명치료중단의 대상 환자, 중단될 수 있는 연명치료의 종류 등 여러 가지가 있지만, 그것이 가장 첨예하게 드러나는 사안은 자발적 호흡을 하고 있지만 이미 장기간의 의식불명상태에 빠져있고 또 앞으로도 상당기간 그 의식불명상태가 계속될 것으로 예측되는, 회복의 가능성이 매우 희박한 지속적 식물상태 환자의 영양공급을 중단할 수 있는가라는 문제라고 생각한다. 본 논문은 법원의 판결과 그 이후의 논의의 전개과정에 대한 검토를 통해 연명치료의 중단에 대한 우리 사회의 합의의 범위를 살펴보고, 연명치료중단이 법제화가 되어야 한다면 그것은 어느 범위에서 연명치료의 중단을 허용하는 것이 되어야 할 것이며 어떤 점에 대한 논의와 합의가 필요한지를 살펴보고자 한다. 그리고 합의의 과정에서 자발적 호흡이 가능한 지속적 식물상태의 환자의 경우에도 연명치료 중단의 가능성을 열어놓고 논의를 하는 것이 필요하다고 제안한다. Owing to the remarkable advances in medical science and technology, terminally ill patients can survive longer than ever expected before. But the patients can not regain consciousness in many cases. The Supreme Court of Korea decided that if a patient is in an irreversible condition with imminent death, the discontinuation of treatment can be approved as the patient`s self-determination, in 2009. In this case, a 76-year-old patient was in a persistent vegetative state, with artificial ventilation treatment. The Court approved the request of the patient to remove the artificial ventilation treatment, and allowed the patient to die. Therefore the artificial ventilation treatment was removed, but the patient maintained spontaneous breathing for about seven months, and deceased. This decision presented the general criteria and process of withdrawal of life-sustaining management in Korea for the first time, the majority opinion of the decision ruled that in state of critically irreversible condition the patient can exercise the right to self-determination based on human dignity, value and the right to pursuit of happiness, the withdrawal can be allowed. However, the court defined the concept of ``irreversible condition`` and ``imminent death condition`` vaguely and there is enough ground for controversy. A generally accepted consensus of end-of-life care decision-making appeared in Korean medical society after that decision, and guidelines to withdrawing life-sustaining therapies were published in 2009. Still there is an opposition to the legalization of the withdrawal of life-sustaining management, the majority of people seem to assent to the withdrawal of life-sustaining management in a specific condition, but in particular there are conflicts of opinion, An advance directive is a measure to certify the determination of incompetent patients, but the persistent vegetative state is so rare and unexpected condition, and it may happened suddenly, If the patient have made out an advance directive, there are many difficulties with advance directives. And withdrawal of life-sustaining artificial nutrition and hydration is more serious and critical problem, especially in case of the persistent vegetative state patient. Therefore national consensus should be made before the legislation of the withdrawal of life-sustaining management, especially about the persistent vegetative state.

존엄사의 헌법적 보장-죽음에 대한 자기결정권의 구성요건 설정을 중심으로-

주재경 원광대학교 법학연구소 2022 圓光法學 Vol.38 No.4

South Korea recognizes death with dignity only in the form of cessation of life-sustaining treatment for patients in the process of dying. Accordingly, a terminally ill patient or a patient in a persistent vegetative state cannot make a decision to die with dignity, and even if he or she is the target, there are limitations in choosing a method of dying with dignity such as physician-assisted suicide. These limitations cannot preclude discussion from the stage of component requirements. Therefore, in the decision to die with dignity, it is necessary to ensure that death with dignity is sufficiently guaranteed through the establishment of the component requirements for the right to self-determination on death. Regarding the requirements for becoming the subject of the right to self-determination on death in the decision to die with dignity, the requirements of irreversibility and the uselessness of treatment become the focal points. Accordingly, it is against the principle of equality to exclude a patient who has no essential difference from a patient in the process of dying and who meets the requirements from the subject. Therefore, in principle, it is desirable to acknowledge the subjectivity of the right to self-determination on death for these patients. First, in terms of the right to defense of the right to self-determination on death, the subject of the decision to die with dignity can request that the state stop restrictions on physician-assisted suicide. In the same respect, it is possible to ask the state to make a decision to discontinue general life-sustaining treatment. Next, based on the social rights aspect of the right to self-determination on death, the subject of decision to die with dignity can claim the right to receive social insurance and public assistance from the state. In particular, it can be requested that the state prepare overall welfare conditions such as hospice and palliative care systems so that patients' self-determination can be free from economic pressure. And, in terms of the protective right of the right to self-determination on death, the subject of the decision to die with dignity may claim the right to receive assistance from a doctor to the state. For example, if death with dignity is carried out by a private person other than a doctor, the right to self-determination on death may be violated, so the patient can request legislation to the state that obligates the participation of doctors in the decision to die with dignity. Lastly, in terms of the procedural right of the right to self-determination on death, in relation to organizations, supplementary legislative requests can be made to the state to expand the establishment or vitalize the operation of the Medical Institution Ethics Committee or the Public Ethics Committee. Regarding the procedure, it may be possible to request the state to prepare legislation to supplement the procedure for implementing death with dignity.

A Study on the Methods to Determine the Wish of a Patient in a Persistent Vegetative State as to Life Sustaining Treatment

공영호 한국외국어대학교 법학연구소 2012 외법논집 Vol.36 No.4

patient’s wish on end-of-life care would be a ideal and logical way to avoid unnecessary emotional and financial burden on the patient as well as the patient’s family. At the same time, it can give a peace of mind to all. Some may consider a choice on end-of-life care as a taboo or a topic that they want to avoid for various reasons. But as almost everyone has a life or health insurance coverage as a safeguard for an unforeseeable future, a preparation of an advance directive may be considered as a protection against an event that can happen to anyone. However, it would be inevitable that some people will be unfortunately in PVS due to an unexpected accident or illness without an advance directive to represent their wish regarding life support treatment. But every patient including patients in PVS has a right to choose his or her wish on end-of-life care and to have it carried out. Simply because a person becomes to be in PVS does it not mean that his wish should be disregarded under the assumption that it is difficult or almost impossible to find out his wish. Every attempt and effort must be made to find out the patient’s wish on end-of-life care regardless of the status of the patient including persistent vegetative state. Every individual has a right to the possession and control of his own person, free from all restraint or interference of others, that should be held sacred and carefully guarded.

지속적 식물상태(PVS)에 관한 의료법학적 고찰

김장한,이정빈,이윤성 大韓法醫學會 1999 대한법의학회지 Vol.23 No.1

This treatise summarizes the medical facts about the persistent vegetative state(PVS) and the associated issues. In August 1998, the opinions of the 380 neurologists and the 1007 neurosurgeons are inquired about the diagnostic criteria of PVS, the degree and the withdrawal of treatment on PVS patients. Theresponse rate is 18,8%. The diagnostic criteria of PVS is determined by the items approved above 50% of responses. (1) no evidence of cerebral function and an inability to interact with visual, auditory stimuli and follow commands.(2) maintaining the respiratory function with spontaneous respiration and normal respiratory pattern. (3) spontaneous eye opening and eye ball movements without sustained tracking. (4) variably preserved brain stem reflexes. (5) presence of sleep-wake cycles. (6) (1)-(5) symptoms should be persist for 6 months after the development of vegetative state. (7) the diagnostic criteria of PVS should be applied more than 3 times during the minimum observation period. (8) this diagnostic criteria of PVS could be applied to adults over 7 ages. As to the degree of treatment, nasogastric tube feeding and air-way keeping through the tracheostomy are approved over 90% . Also antibiotics can be used in infection. As to the withdrawal of treatment, do not resuscitate order of patient's family is accepted by 46.1% in an emergency condition like cardiac arrest. But discharge against medical advice by the patient's family is accepted by 73.1% in non-emergency condition. In the case of neonates, parents' decision is more determinative than any other thing.

연명치료중단의 기준과 절차 : 대법원 2009. 5. 21. 선고 2009다17417 판결이 가지는 문제점을 중심으로

이석배(Lee Seok-Bae) 한국형사법학회 2009 刑事法硏究 Vol.21 No.2

Die jetzt 77-jährige Ptientin erlitt im Februar 2008 infolge eines Herzstillstandes durch eine ärztliche Fahrlässigkeit einen hypoxischen Gehirnschaden im Sinne eines apallischen Syndroms (persistent vegetative state; permanent vegetative state: PVS). Seither wird sie vom Beatmungsgerät abhängt und über eine PEG-Sonde ernährt; eine Kontaktaufnahme mit ihr ist nicht möglich. Die Tochter der Patientin als eine spezielle Bevollmächtigte hat den Antrag auf die gerichtliche Genehmigung zum Abschalten des Beatmungsgeräts gestellt. Am 21. 5. 2009 hat the Supreme Court of Korea für den vorliegenden Fall die Zulässigkeit des Abschaltens des Beatmungsgeräts bejaht. Es hat dabei die Voraussetzungen des zulässigen Behandlungsabbruchs des lebenserhaltenden oder -verlängernden Maßnahmen allgemein Stellung genommen und auch die Bedeutung sog. Patientenverfügungen unterstrichen: Sei ein Patient einwilligungsunfähig und habe sein Grundleiden einen irreversiblen tödlichen Verlauf angenommen, so könnten lebenserhaltende oder -verlängernde Maßnahmen unterbleiben, wenn dies seinem zuvor - etwa in Form einer sog. Patientenverfügung - geäußerten Willen entspreche. Dies folge aus der Würde des Menschen, die es gebiete, sein in einwilligungsfähigem Zustand ausgeübtes Selbstbestimmungsrecht auch dann noch zu respektieren, wenn er zu eigenverantwortlichem Entscheiden nicht mehr in der Lage sei. Nur wenn ein solcher erklärter Wille des Patienten nicht festgestellt werden könne, beurteile sich die Zulässigkeit solcher Maßnahmen nach dem mutmaßlichen Willen des Patienten, der dann individuell - also aus dessen Lebensentscheidungen, Wertvorstellungen und Überzeugungen - zu ermitteln sei. In diesem Beitrag habe ich diese Entscheidung anmerkt udn aber auch eigeneLösungsvorschlag gemacht.

뇌사도 죽음이다

이인수 순천향대학교 1991 논문집 Vol.14 No.2

옛날부터 폐, 심장 및 뇌기능의 불가역적 정지를 죽음으로 정의하고, 죽음의 세징후로 호흡정지, 심박동정지와 동공산대(散大)와 광반사 소실을 확인하고 의사는 사망을 선언한다. 그리고 심박동정지 순간을 사망시간으로 정하여 사망진단서를 발급하는 것이 관습으로 내려오고 있다. 동공산대와 광반사 손실을 뇌기능 정지로 판단하고 죽음을 판정하나, 가장중요한 징후는 심박동정지로서 이로 말미암아 놔와 폐와 기타 모든 장기 기능이 조속히 그리고 확실히 상실되며, 또한 비교적 쉽고 명확하게 죽음을 판정할 수 있다. 이 세 징후를 확인하여 죽음을 결정하는 것이 심장사의 개념이다. 사람은 신장이나 간장 또는 심장이 완고한 질병으로 기능하지 못하게 되었을 때에 그들 장기를 이식하거나 인공장기를 사용하면 살아갈 수 있다. 그리고 호흡과 심장박동이 정지되어 혈액순환이 완전히 정지되어도 피하조직의 세포는 며칠 더 살수 있다. 또한 적당한 보조장치로 영양을 공급하면 기타 조직이나 장기까지도 그 자체로서 오랫동안 살아 갈수 있다. 오늘날에는 첨단기술의 발달로 죽음을 확인한 다음에도 동물의 정자나 난자를 채취하여 수정시키면 새로운 개체를 발생시킬 수도 있다. 즉 생물체의 일부가 사망하여도 적당한 보조로써 다른 부분을 살리고 증식시킬 수도 있다. 그러나 사람을 비롯하여 고등 다세포 동물의 경우, 그 삶의 특징이 생체를 구성하는 모든 세포와 장기가 서로 협동하여 통합 조절된 기능을 영위하는데에 있다. 그리고 그 통합된 기능은 일대로 끝나는 것이다. 그러므로 죽음의 상태는 인체를 구성하는 세포와 장기를 통합하는 능력이 완전히 소멸된 상태라고 하겠다. From ancient time declaration of death has been based upon the traditional cessation of cardiac respiratory activity. However the development of respiratory and cardiac resuscitation measures in the middle of the twentieth century literally restored life to the heart and lungs, but rnight leave more sensitive organ such as the brain in a non-functional state. And so a person incapable of breathing and without ability to respond may, by reason of a mechanical respirator, have a beating heart. But is that individual alive? His breathing and cardiac action will cease eventually in a few days. Since physicians have introduced a new concept of death based upon the demonstration of a permanently non-functional brain in the past 30 years, the brain death has been socially and legally accepted as the basis for the pronouncement of the death in many countries of the Europe and the America, and a few of the Asia. Although loss of cardiorespiratory activity is generally the basis for the pronouncement of death in Korea, there is a growing interest in the thesis that the master organ, the brain, no longer functions, life is at an end. The author discusses the changing concept of death and presents the newer criteria for the determination of a dead brain established in the Korean Medical Association in March 1989. The concept of brain death might be better accepted as the basis of individual death soon in Korea.