The vegetative state − clinical diagnosis
- KEITH ANDREWS, Director of Medical & Research Services
- Royal Hospital for Neuro-disability, West Hill, Putney, London, UK
- Accepted 15 January 1999
Rare conditions occasionally have a major impact on medicine and society. The vegetative state is one such disorder − not only in the controversies of how to treat but also whether to treat. The case of Tony Bland, a young man becoming vegetative due to severe anoxic brain damage when he was crushed in the Hillsborough football disaster, hit the headlines and has been the basis for much debate about withdrawal of nutrition and hydration, the right to die and euthanasia. The very high cost of caring for vegetative patients over several decades has important implications in legal cases and in the use of resources. There is still, however, a considerable misunderstanding about the condition.
Terminology
In spite of attempts to have clear terminology, Giacino and Zasler1 have pointed out that there is still “a relative lack of understanding of the existing nomenclature and a tendency toward inappropriate diagnoses and subsequently incorrect conclusions regarding neurological and functional prognoses and necessary treatment”.
The term ‘persistent vegetative state’ (PVS) was coined by Jennett and Plum2 to describe a specific syndrome of reflex reactions without any meaningful response to the environment but in patients who have a sleep–awake pattern. They introduced the term because they were generally unhappy about the other terms used at the time. These terms either use categories which were not true, eg, prolonged coma 3 4 orcoma vigil5 (when the patients, by definition, were not in coma), or were of specific syndromes, eg, decerebrate dementia,6 parasomnia,7 or akinetic mutism.8 The term apallic syndrome,9still used in Germany, implies lack of the cortex which may not be the case, especially in traumatic injuries.
There is nevertheless a dislike, especially amongst relatives of brain-damaged people, of the term ‘vegetative’ mainly because of its association …
