UK doctors breach guidance on persistent vegetative stateBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7080.535e (Published 22 February 1997) Cite this as: BMJ 1997;314:535
Doctors' views on the management of patients in a persistent vegetative state conflict with official guidelines, says a report published last week.
The report, produced by the Centre of Medical Law and Ethics, King's College, London, is the first large scale survey of the views of UK doctors on this subject. Of the 1882 consultants in neurosurgery, neurology, orthopaedic surgery, and rehabilitation medicine who were contacted, 1027 replied.
The results showed that over 90% of doctors who replied said that it can be appropriate not to treat acute infections and life threatening conditions in patients in a persistent vegetative state. Almost three quarters said that it was sometimes appropriate to withdraw artificial nutrition and hydration.
Although the BMA guidelines state that decisions to withdraw treatment should be considered only after 12 months, a third of doctors said that they would consider withdrawing treatment before six months.
Professor Andrew Grubb, professor of healthcare law at King's College, London, and one of the authors of the report, said that he was surprised that so many doctors thought that this kind of decision could be made earlier than current guidelines. Guidelines produced by the BMA were adopted by the courts in 1993 during the case of Anthony Bland who suffered severe brain damage during the Hillsborough football stadium disaster.
Professor Grubb said that he was “troubled by the ease with which some doctors disregard the views of others involved-nurses, for example-in making such a decision,” and he added that doctors should take more note of advance directives given by patients.
Of the doctors surveyed, 40% said that they were either quite confident or very confident about predicting the ultimate outcome for such a patient between the fourth and the sixth month. However, recent research has shown that this confidence is misplaced. A paper published in the BMJ (1996;313:13-6) showed that of 40 patients admitted to a specialist unit as being in a persistent vegetative state, almost half were given a misdiagnosis. Seven of the patients had been considered to be in a persistent vegetative state for over a year.
Dr Keith Andrews, consultant in disability medicine at the Royal Hospital for Neurodisability, London, and author of the BMJ paper, estimates that there are about 1000 patients in the UK who have been vegetative for over three months. He said: “This is a very rare condition so doctors do not get the chance to develop expertise. Assessment needs to be over a long period of time and is a team effort.”
Key findings of report on persistent vegetative state
Over 90% of doctors said that it can be appropriate not to treat acute infections and life threatening conditions in patients in a persistent vegetative state
One in three doctors said that it was sometimes appropriate to withdraw artificial nutrition and hydration
Three out of four doctors disagreed with such cases coming before the courts, as required in current law
Most (78%) doctors thought that parliament should bring in a law allowing doctors to decide whether to withdraw artificial nutrition and hydration in consultation with the family and in accordance with agreed guidelines
Most doctors think that patients in a persistent vegetative state are best cared for at a specialist unit
Doctors Views on the Management of Patients in Persistent Vegetative State (PVS): a UK Study can be obtained from the Centre of Medical Law and Ethics, King's College, London WC2R 2LS, price £12.