The withdrawal of clinically assisted nutrition and hydration (CANH) is a legally and ethically complex intervention governed by distinct frameworks across the world. In the UK, the British Medical Association (BMA) and Royal College of Physicians (RCP) guideline on CANH, formulated in 2018 after a Supreme Court ruling, provides a framework for decisions. In contrast, Islamic law treats nutritional support as basic care, and its withdrawal is prohibited unless it causes direct harm or there is the presence of an advance directive. Cross-jurisdictional cases where a patient moves between these legal frameworks are rarely described in published literature. We report the case of a 61-year-old woman with no co-morbidities who was in Qatar in November 2024 when she had an out-of-hospital cardiac arrest, resulting in a hypoxic brain injury and later a persistent vegetative state. Her family requested withdrawal of care, citing her wishes to avoid living with a disability. The hospital consulted its ethical and legal departments and concluded that they could not withdraw nutrition as there was no prior explicit directive from the patient. She was repatriated to her local hospital in the UK after eight weeks. She remained in a vegetative state, and her brain imaging was unchanged. Her care team followed the BMA/RCP CANH 2024 guidelines to assist with the process of withdrawing nutrition and hydration and obtained further specialist and legal team opinions. Letters of support from family and friends were also collected. Supportive treatment was withdrawn nine days after UK repatriation, and she died three weeks later with palliative team input. This case illustrates the practical challenges of applying CANH withdrawal guidelines across jurisdictions with different legal and ethical frameworks. It demonstrates the importance of a robust, workable framework like the BMA/RCP guideline on withdrawal of CANH. It highlights the value of advance directives, close family involvement, and legal framework in clinical decisions. Clinicians caring for Muslim patients should be aware of the Islamic bioethical perspective on CANH, which may shape family expectations and discussions in similar situations.

The Supreme Court (SC) of India's judgment on March 11, 2026, in Harish Rana vs Union of India brought greater clarity on the complex issue of end-of-life decisions; specifically on withdrawal of care from persons in a "permanent vegetative state" [1]. In an earlier landmark judgment in Aruna Shanbaug vs Union of India in 2011, the Court had allowed petitions in favour of "withholding or withdrawal of life support" to allow "a dignified death", in very rare cases, following specific procedures outlined in that judgment [2]. In 2018, in Common Cause vs Union of India, the SC recognised the "right to die with dignity" as an extension of the fundamental "right to live with dignity" under Article 21 of the Indian Constitution. Patients who were terminally ill could refuse futile or burdensome treatment and could register Advance Directives, against unnecessary suffering caused by such treatment [3]. That judgment detailed the decision-making process to be followed for withdrawal of treatment, in order to protect vulnerable patients and prevent misuse. These procedural steps were later simplified by the SC in 2023 into what is termed "Common Cause Guidelines 2023" [4].

A 23-y-old female rhesus macaque (Macaca mulatta) from a long-term research colony developed progressive clinical decline, with lethargy, nasal discharge, and hematologic abnormalities, including persistent leukocytosis, neutrophilia, thrombocytopenia, and anemia. Despite treatment with enrofloxacin, deterioration led to euthanasia. Autopsy revealed severe vegetative endocarditis of the left atrioventricular (mitral) valve with intralesional gram-positive cocci, confirmed immunohistochemically as Staphylococcus aureus. Histologically, disseminated thromboembolic arterial disease was present in the lungs, tracheobronchial lymph node, kidneys, and spleen, with concurrent hepatic central vein thrombosis and coagulative necrosis of hepatocytes, supporting a concurrent hypercoagulable state. A PCR assay of the mitral valve tissue targeting the bacterial 16S ribosomal RNA gene was negative for S. aureus (interpreted as a false-negative result), acknowledging the limitation of PCR testing of formalin-fixed tissues caused by DNA damage and fragmentation. The absence of heart-failure cells and pulmonary edema made primary congestive heart failure unlikely and instead supported systemic inflammatory response syndrome with secondary multi-organ ischemic injury as the cause of death. In infective endocarditis, sustained bacteremia and inflammatory mediator release drive endothelial dysfunction, a hypercoagulable state, and widespread microvascular thrombosis, resulting in impaired tissue perfusion and organ failure.[8,22] Accordingly, the dominant life-threatening process in our case was not mechanical cardiac failure, but disseminated thromboembolic disease and ischemic injury to downstream organs. This pattern is well recognized in both human and veterinary literature; morbidity and mortality in infective endocarditis are frequently driven by septic embolization and systemic complications, rather than intrinsic cardiac dysfunction.

Brainstem auditory evoked potentials (BAEP) provide an objective assessment of brainstem functional integrity. However, their characteristic profiles and clinical significance in patients with prolonged disorders of consciousness (pDOC) remain to be fully elucidated, especially in small, well-characterized cohorts. This is an exploratory study that examines the characteristics of brainstem auditory evoked potential parameters in a small sample of patients with chronic disorders of consciousness and explores how these parameters correlate with the level of consciousness impairment. In this cross-sectional study, 29 patients with pDOC (16 with unresponsive wakefulness syndrome [UWS] and 13 in a minimally conscious state [MCS]) were enrolled. BAEP recordings, neurological assessments using the Coma Recovery Scale-Revised (CRS-R), and medical record reviews were performed. BAEP parameters (wave latencies, interpeak latencies [IPLs]) were compared between UWS and MCS groups using Mann-Whitney U tests. Effect sizes (r) were calculated to quantify the magnitude of observed differences. Spearman correlation was used to assess the relationship between BAEP parameters and CRS-R scores. No significant differences were observed in the latencies of wave I, wave III, the I-III interpeak interval (IPL), the III-V IPL, or the I-V IPL between the unresponsive wakefulness syndrome (UWS) group and the minimally conscious state (MCS) group (all p > 0.05). However, the study revealed a trend toward prolongation in the latency of wave V and the I-V IPL in the UWS group (wave V latency: p > 0.05; I-V IPL: p > 0.05). Both wave V latency (r = - 0.342) and I-V IPL (r = - 0.354) demonstrated moderate effect sizes, suggesting the presence of substantive differences in these measures between the two groups. Additionally, a moderate negative correlation was observed between the I-V IPL and the total score of the Coma Recovery Scale-Revised (CRS-R) (Spearman's ρ = - 0.447, p < 0.001). Although no significant differences were observed in the brainstem auditory evoked potential (BAEP) parameters between the two patient groups, the trend of prolonged I-V interpeak interval (IPL) in the unresponsive wakefulness syndrome (UWS) group, along with its moderate correlation with the Coma Recovery Scale-Revised (CRS-R) score, suggests that UWS patients may have more severe brainstem dysfunction. Therefore, BAEP remains a promising electrophysiological marker for assessing brainstem impairment in patients with prolonged disorders of consciousness (pDOC). Although these preliminary findings did not reach statistical significance in intergroup comparisons, they highlight the need for larger sample sizes in future studies to clarify the role of BAEP in the evaluation of consciousness disorders. If combined with EEG, functional neuroimaging, and other examinations, it would further enhance the accuracy of diagnosis and prognosis.

Over the last two decades, many legal developments and professional recommendations notwithstanding, end-of-life practice on the ground is limited by physician hesitancy, lack of commitment to ensure appropriateness in decision-making, persistent fear of legal liability, and inadequate attention to quality of dying. This commentary attempts to spell out the salient messages in the recent Harish Rana vs Union of India judgment and reiterates the essential components of end-of-life care (EOLC) in intensive care unit (ICU) practice. Thoughtful and compassionate care is integral to critical care practice.

Early detection of consciousness in critically ill patients with severe brain injuries can profoundly impact prognostication and clinical care decisions. Advanced multimodal protocols to detect signs of consciousness include standardized behavioral assessments, task-based functional magnetic resonance imaging (fMRI), and task-based electroencephalography (EEG). However, these approaches have limited diagnostic sensitivity because patients may lack auditory function, attention, language, or other cognitive capacities required to perform a task or process a sensory stimulus, even if they are conscious. Transcranial magnetic stimulation EEG (TMS-EEG) has the potential to overcome these limitations by directly engaging corticothalamic circuits to compute the perturbational complexity index (PCI), an emerging indicator of consciousness. To date, TMS-EEG studies have focused on patients in the subacute or chronic stage of recovery from severe brain injury. Here, we report the proof-of-concept application of TMS-EEG for a critically ill patient in the acute stage of brain injury, in which multimodal assessments suggested a vegetative state/unresponsive wakefulness syndrome. We demonstrate that TMS-EEG may detect signs of consciousness that elude current advanced evaluations, showing the feasibility of TMS-EEG as part of a multimodal protocol for assessing consciousness in the intensive care unit.

While wetland construction and restoration are widely employed as nature-based solutions to achieve various eco-environmental goals, their roles in affecting diffusive greenhouse gas (GHG) emissions from the targeted riverine systems remain poorly understood. In this study, we investigated the monthly and diurnal dynamics of diffusive GHG emissions in a headwater river, which initially contained a series of constructed wetlands but were later destroyed. Our findings reveal that the riverine reach with wetlands was a persistent source of diffusive CH4 and CO2 emissions, but a periodic sink for N2O, with mean fluxes of 0.76 mmol m-2 day-1, 262.38 mmol m-2 day-1, and 5.44 μmol m-2 day-1, respectively. The hotspots for CH4 and CO2 and sinks for N2O emissions occur coincidentally in warm months, when vegetative and microbial activities are strong. Once the wetlands were destroyed, we observed reductions in the emission fluxes of N2O (9.62%), CH4 (27.23%), and CO2 (47.73%). Further analysis underscored that the environmental settings as shaped by wetlands foster anaerobic metabolisms, whereas the loss of wetlands reduces nutrient trapping and induces more aerobic conditions, which hinder anaerobic activity and associated GHG production. The comparative nature of this study uniquely illuminates the roles of wetlands in governing diffusive GHG dynamics, providing a valuable, data-driven starting point for a more refined evaluation of their net impact on aquatic GHG budgets.