I am writing a novel in which a 72 year old man has a stroke and goes
into a coma. It suits my dramatic purposes to have him stay in a coma
for about 5 months before dying. I need to know if this time frame is
credible and if so, what sort of medical decisions/interventions might
have to be made along the way. Also, what is most likely to kill him off in
the end? If you need any further clarification of this question,
please let me know.

---

Clarification of Question by screenwriting101-ga on 08 Feb 2006 06:52 PST

I don't want my character murdered. I need to know what he is likely
to die of, after 5 months of a post-stroke coma.

Hi screenwriting101-ga, and thanks for your question.

First off, the scenario of stroke leading to coma is certainly
realistic.  Coma lasting 5 months is also not unrealistic.  It is much
more realistic for a patient to die of secondary disease rather than
awake after such a prolonged coma as well, so I think you're on the
right track.

Often, patients need to be intubated after ischemic stroke or
intracranial hemorrhage (an tube is placed into the trachea so that a
respirator can breath for the patient).  After several days of not
eating, nutrition is often provided via Total Parenteral Nutrition
(TPN), which looks like a big bag of white liquid that's infused into
a large vein over the course of about 12-24 hours.  This is somewhat
hard to do long term.  In this situation, where a patient will require
prolonged intubation and nutritional support, surgeons will often
perform a "trach and PEG," where a tracheostomy is performed (a hole
(ostomy) is made in the neck into the trachea and a short plastic bent
tube is place into the trachea and tied in place around the neck). 
The PEG (percutaneous endoscopic gastrostomy) portion of the
procedures involves placing a tube through the skin of the abdomen
into the stomach so that nutrition can be provided directly to the
gut, which is preferred over TPN.  Often, only one of these procedures
is performed (for example, if the patient is not intubated, but still
requires a PEG for nutrition).

You may be interested in, for example, this study, which looked at
survival in patients who required intubation.  One of the predictors
of survival was GCS (Glasgow Coma Score):

"Survival was 51% at 30 days and 39% overall. Variables that
significantly correlated with 30-day survival in multivariate analysis
included GCS at intubation (p = 0.03) and absent pupillary light
response (p = 0.008). Increase in the GCS also correlated with
improved functional outcome measured by the BI (p = 0.0003). In
patients with IS, age and GCS at intubation predicted survival, and in
patients with ICH, absent pupillary light response predicted
survival."

Bushnell CD, Phillips-Bute BG, Laskowitz DT, Lynch JR, Chilukuri V,
Borel CO.  Survival and outcome after endotracheal intubation for
acute stroke.  Neurology. 1999 Apr 22;52(7):1374-81.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10227620&dopt=Abstract

You can read about the GCS here:
http://www.trauma.org/scores/gcs.html

Also, atrial fibrillation and heart disease are common comorbid
conditions in stroke patients.  Sometimes, patients develop heart
problems (heart attack, etc.), which causes ischemia in the brain and
stroke.

________


Here are some similar articles for which the full text is available:

Foerch C, Kessler KR, Steckel DA, Steinmetz H, Sitzer M.  Survival and
quality of life outcome after mechanical ventilation in elderly stroke
patients.  J Neurol Neurosurg Psychiatry. 2004 Jul;75(7):988-93.

http://jnnp.bmjjournals.com/cgi/content/full/75/7/988


Table 1 of this article shows the mean 6 month survival for various
types of stroke (vascular territories).
http://jnnp.bmjjournals.com/cgi/content/full/75/7/988/T1

Table 2 shows survival for various variables, such as coma at time of
admission.  In this case, 42% of patients who presented in a coma were
alive at 6 months:
http://jnnp.bmjjournals.com/cgi/content/full/75/7/988/T2



Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W.
Prognosis of stroke patients requiring mechanical ventilation in a
neurological critical care unit.  Stroke. 1997 Apr;28(4):711-5.

http://stroke.ahajournals.org/cgi/content/full/28/4/711


===============================

In terms of what someone in a coma secondary to stroke might die from,
after the initial stroke, the primary "condition" would be coma.   I
ran some data through the HCUP database to see what conditions are
most associated with stroke and with coma.  You can also see the
frequency of each condition and how often patients with each
associated condition died while in the hospital.  Here are the
results:

Conditions associated with stroke:
http://img288.imageshack.us/img288/7421/snapshot200602082133314vm.jpg

Conditions associated with coma:
http://img288.imageshack.us/img288/1995/snapshot200602082138068dl.jpg

As you can see from the previous table, patients who came in with a
stroke and developed respiratory failure had a 50% mortality rate.  It
is also very common for patients in comas or on a ventilator for
prolonged periods of time to develop intractable pneumonias, from
which they often die.   The incidence of pneumonia after stroke is
21-33%. The mortality rate for patients who develop pneumonia after
being hospitalized for stroke is 24-27%.

Katzan IL, Cebul RD, Husak SH, Dawson NV, Baker DW.  The effect of
pneumonia on mortality among patients hospitalized for acute stroke. 
Neurology. 2003 Feb 25;60(4):620-5.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12601102&query_hl=31&itool=pubmed_docsum


Hilker R, Poetter C, Findeisen N, Sobesky J, Jacobs A, Neveling M,
Heiss WD.  Nosocomial pneumonia after acute stroke: implications for
neurological intensive care medicine.  Stroke. 2003 Apr;34(4):975-81.
Epub 2003 Mar 13.
http://stroke.ahajournals.org/cgi/content/full/34/4/975


Another not so uncommon problems are decubitus ulcers from lying in
the same position for an extended period of time.  These skin
ulcerations often become infected and can lead to bone infections
(osteomyelitis) and systemic infection (sepsis), which can be lethal. 
There can also be infections around the traceostomy or PEG sites. 
Often patients in these states are made DNR (Do Not Resuscitate) or
"comfort measures only" by their families or health care proxy.  One
difficult situation that sometimes arises when the patient is unable
to express their wishes and multiple close family members, who are all
next of kin (say two brothers), disagree on what the patient's wishes
would have been or have conflicts over their personal beliefs (e.g.,
euthanasia, etc.)  There's nothing like a death in the middle of a
legal battle to make people remember what's really important.

_____________


In relation to what other procedures might be performed, here are the
statistics on procedures performed on stroke and coma patients and the
percentage patients receiving each procedures who ultimately died:

Stroke procedures:
http://img147.imageshack.us/img147/8544/snapshot200602082147144yg.jpg

As you can see from the above table, patients who came in to the
hospital with stroke and ended up needing a tracheostomy had a mean
hospital stay of 33 days (half stayed longer than 28 days) and had an
18% overall mortality rate.

Coma procedures:
http://img147.imageshack.us/img147/4849/snapshot200602082150411mn.jpg


Here's a link to the HCUP database:
http://hcup.ahrq.gov/HCUPnet.asp

_______________

Here are some additional resources on coma and death:

Approach to a Patient in Coma
http://www.neuro.mcg.edu/amurro/coma/

How Stuff Works
http://health.howstuffworks.com/brain-death3.htm

Coma Recovery
http://www.comarecovery.org/artman/publish/BrainDeath.shtml

Wikipedia
http://en.wikipedia.org/wiki/Coma


==========================================

I hope this information is helpful.  Please feel free to request any
clarification prior to rating.  Best of luck with your writing!

        -welte-ga

Very thorough and very helpful.

I think the information found on following sites will help you to
understand, how a person goes into a coma and how he is treated.

http://health.enotes.com/medicine-encyclopedia/coma
http://www.biausa.org/Pages/what_is_the_rehab_process.html

About killing and old man, it seems, that the usual case of death from
coma is brain death, or irreversible changes in brain structure. When
one part of a brain shifts to another place. If you don't want to get
rid of him in this simple way, or use some relatives to kill him. He
can die later from damage caused to his brain by coma, or he can have
an insult.
Additional material on death from coma cases can be found at:

http://www.neuro.mcg.edu/amurro/coma/index.html#braindeath
http://www3.baylor.edu/~Charles_Kemp/terminal_illness/death.htm

I would believe that coma for 5 months before dying is not inaccurate
under medical terms. Comas are unpredictable by nature; they can last
from 1 day to many years. Some real people suddenly recover from a
decade or so of coma, while other die after it. Of course, any such
event or phenomenon in a story, whether coma or death or recovery,
needs a cause or rationale to make it fit the story. Detailing the
medical condition of your character is not needed, but can add to the
believability of the story.

A beneficiary under his will has to be the main suspect.

She (I assume it is a she) would hold a pillow over his face.

Perfect!

I can't wait for your novel to get published.

Please hurry!

Stephen King wrote a novel about a guy who went into a 30 year (?) coma
- the physical effects were alarming - doubtless well researched

Five months would lead to considerable muscle wastage, even a month in
a plastercast has interesting effects.

His termination probably needs to be something hinted at early on, but
apparently unusual and unexpected.

Medication would be added to his drip feed, an accident by a nurse
while she is distracted by, say his male (or female :-) ) heir, would
be ironic, especially if it happened a few days before some
financially important date.

Worth checking whether they ever inject an IV tube rather than the bag ...
- routine and strictly timed dosing would make it look like clockwork gone wrong

And the whole lot goes to a retirement home for ... something trivial
and rather unlikely to inspire sympathy in your audience.

He is most likely to die of pneumonia or MRSA

Although the death certificate would say 'liver failure'