Vegetative stateThe vegetative state, another product of modern technology, was first described in 1972 (4). The vegetative state is best understood as an eyes-opened unconsciousness; there is a disassociation between wakefulness and awareness. While patients may appear awake, there is a lack of evidence that the upper brain receives or projects information. The upper brain and the midbrain are not integrated in function with the brain stem or the rest of the body, although the brain stem continues to manage the vegetative functions. This is the condition that Karen Quinlan, Nancy Cruzan, and Terri Schiavo were in following their serious brain injuries up until the moment of their deaths.The most authoritative published data on the vegetative state come from the Multi-Society Task Force on the Persistent Vegetative State. This group established definitive diagnostic criteria and published authoritative outcomes data on 700 patients (5,6).As with the diagnosis of brain death, the diagnosis of a vegetative state is a clinical judgment based on several criteria(Table(Table33). The notion of a sustained and reproducible voluntary response is important in the diagnosis. Hope is eternal in families. They want to believe that their loved one is conscious, and they report instances when their loved one responds to them. As an ethics consultant, I often try to be at the bedside with family members who believe their loved one is responding to them. I insist that we first remain quietly at the bedside without disturbing the patient during a wake cycle for prolonged periods of time. These patients may have a variety of nonpurposeful movements. It is important for families to see these movements occurring in the absence of any external stimuli before they try to elicit a purposeful movement; otherwise, to the untrained eye, these patients may appear to be interactive when they are not. Truly vegetative patients will not have reproducible responses to stimuli.Criteria for clinical diagnosis of a vegetative state* No interaction with others or awareness of self when awake

No comprehension or expression of language

No sustained and reproducible voluntary or purposeful response to external stimuli

Spastic limbs may move nonpurposively

Noxious stimuli may cause reflex withdrawal

Some emotive events may occur, such as smiles or grimaces, but not as a reproducible response to stimuli

The prognosis for recovery is a key concept and is an essential feature of the moral analysis dealing with patients in a vegetative state. Prognosis is determined by the cause of the injury, the length of time the patient has been in the vegetative state, and comorbid conditions. Posttraumatic vegetative patients have a better chance for some recovery than anoxic brain injury vegetative patients(Table(Table44). Although not reflected in the table, the task force found no returns to consciousness in patients like Quinlan, Cruzan, and Schiavo, who had been vegetative with an anoxic injury for over 2 years.1-year outcomes in patients in the vegetative state*Outcome 1 year later

Patient groupDeadVegetativeConscious

Traumatic causes of vegetative state

Vegetative at 1 month28%18%54%

Vegetative at 3 months31%30%39%

Vegetative at 6 months28%53%19%

Nontraumatic causes of vegetative state

Vegetative at 1 month47%39%14%

Vegetative at 3 months36%58%6%

Vegetative at 6 months18%81%1%

The duration of the vegetative state also affects nomenclature. A duration >1 month is said to be persistent. When the cause of the vegetative state is nontraumaticsuch as an anoxic injury after cardiopulmonary resuscitationa duration >3 months is said to be permanent, but when the cause of the vegetative state is traumatic, a patient must remain vegetative for >12 months before the condition is defined as permanent. The distinction between outcomes from posttraumatic versus anoxic brain injuries may play into the moral decisions we must face when confronted by profound brain injury.Finally, comorbid conditions are important factors in determining prognosis. There is a significant difference in survival for the otherwise healthy 25-year-old vegetative patient and the 75-year-old vegetative patient who also has multiorgan system failure. Younger patients, in particular, may survive for decades with artificial nutrition and hydration (ANH). Although these patients may be cared for at home, they often end up in nursing homes. Unless the family is quite wealthy or the patient has extraordinary insurance, the patient often winds up in a Medicaid nursing home where the quality of care can be marginal, with one registered nurse for every 20 or 30 patients. If ANH is not withdrawn, these patients typically die of pneumonia, urinary tract infections, or sepsis related to skin breakdown.Over the years, a variety of treatments have been attempted to try to reverse a vegetative state. None of the treatments has been successful enough to become routine practice. Some neonatologists have suggested promising experimental outcomes with neural stem cells and predict that clinical applications may be available in the next decade or two. It is of more than passing interest that many people who opposed the withdrawal of ANH in the Schiavo case also oppose stem cell research, which might one day help treat such patients.DAPUS4.Jennett B, Plum F. Persistent vegetative state after brain damage.Lancet.1972;1:734737.[PubMed]5.Multi-Society Task Force on PVS Medical aspects of the persistent vegetative state (1)N Engl J Med.1994;330:14991508.[PubMed]6.Multi-Society Task Force on PVS Medical aspects of the persistent vegetative state (2)N Engl J Med.1994;330:15721579.[PubMed]