New guidance on diagnosing and managing patients in the vegetative state were issued this week by the Royal College of Physicians, updating and clarifying guidelines issued in 1996 and correcting apparent inconsistencies in the earlier advice.
The college revised the guidance after the official solicitor, Laurence Oates, passed on a request from Dame Elizabeth Butler-Sloss, president of the High Court's family division, for clarification. Dame Elizabeth presides over cases where court approval is sought for the withdrawal of artificial nutrition and hydration.
Mr Oates told the BMJ there were a few passages in the Royal College of Physicians' 1996 guidelines that were “difficult to square” with guidelines from an international working party published the same year by the Royal Hospital for Neuro-disability in London. Some expert witnesses had told Dame Elizabeth that they preferred to use the international working party's guidelines. One area of difficulty was whether patients who could track objects with their eyes could be said to be in a permanent vegetative state. The new guidelines describe tracking as a “compatible but atypical” feature.
The guidance emphasises that permanent loss of awareness is the important element in deciding to withdraw treatment—the courts have accepted that artificial feeding counts as treatment and may therefore lawfully be withdrawn. Awareness is defined as the ability to have an experience of any kind; patients in permanent vegetative state are awake but not aware.
Professor David Bates, who chaired the working party, said: “The change in the last decade is to recognise that the single cardinal feature is loss of awareness. The new guidelines have been drawn up to incorporate recent evidence and correct perceived inconsistencies in the original document. They have been widely circulated and represent a consensus of current opinion and advice.”
The report clarifies the distinction between persistent vegetative state and permanent vegetative state, terms which have sometimes been used interchangeably in the past. It defines persistent vegetative state as one lasting four weeks or more. A vegetative state lasting at least one year in trauma cases and six months in non-traumatic cases may be considered permanent. The abbreviation PVS is used only for the permanent vegetative state. Although permanent vegetative state cannot be diagnosed with absolute certainty, a patient's chances of regaining awareness decrease considerably as the time spent in the vegetative state increases, the report says.
The working party warns that both the initial diagnosis of the vegetative state and the subsequent diagnosis of permanent vegetative state should be made with great care because of evidence that the state has been diagnosed in error.
“Mistakes have occurred due to confusion about the meanings of the term, inadequate observation of the patient in suboptimal circumstances, failure to consult those who see the patient most (especially family members) and the great difficulty of detecting signs of awareness in patients with major perceptual and motor impairments.”
The Vegetative State: Guidance on Diagnosis and Management is available from the RCP Publications Department (tel 020 7935 1174)