BMJ 1996;313:13-16 (6 July)

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Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit

Keith Andrews, director of medical services,a Lesley Murphy, senior clinical psychologist,a Ros Munday, senior occupational therapist,a Clare Littlewood, senior occupational therapist a

a Royal Hospital for Neurodisability, London SW15 3SW

Abstract

Objective: To identify the number of patients who were misdiagnosed as being in the vegetative state and their characteristics.
Design: Retrospective study of the clinical records of the medical, occupational therapy, and clinical psychology departments.
Setting: 20 bed unit specialising in the rehabilitation of patients with profound brain damage, including the vegetative state.
Subjects: 40 patients admitted between 1992 and 1995 with a referral diagnosis of vegetative state.
Outcome measures: Patients who showed an ability to communicate consistently using eye pointing or a touch sensitive single switch buzzer.
Results: Of the 40 patients referred as being in the vegetative state, 17 (43%) were considered as having been misdiagnosed; seven of these had been presumed to be vegetative for longer than one year, including three for over four years. Most of the misdiagnosed patients were blind or severely visually impaired. All patients remained severely physically disabled, but nearly all were able to communicate their preference in quality of life issues--some to a high level.
Conclusions: The vegetative state needs considerable skill to diagnose, requiring assessment over a period of time; diagnosis cannot be made, even by the most experienced clinician, from a bedside assessment. Accurate diagnosis is possible but requires the skills of a multidisciplinary team experienced in the management of people with complex disabilities. Recognition of awareness is essential if an optimal quality of life is to be achieved and to avoid inappropriate approaches to the courts for a declaration for withdrawal of tube feeding.

Key messages

  • Many patients who are misdiagnosed as being in the vegetative state are blind or have severe visual handicap; thus lack of eye blink to threat or absence of visual tracking are not reliable signs for diagnosing the vegetative state

  • Any motor activity, no matter how slight, that can be used for communication by the profoundly disabled patient should be identified at an early stage and repeated at regular intervals

  • Identification of awareness in the presence of profound and complex neurological disabilities requires the skills of a multidisciplinary team expe- rienced in long term management of disability due to brain damage


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