Confusion among the public over the difference between brain stem death and a persistent vegetative state can make it difficult to obtain consent to withdraw ventilation. Clinicians who have been faced with this dilemma outline their strategies for coping with such a situation, and a neurologist and a neurosurgeon offer their opinions.

The concept of brain death is not often discussed in the public arena. According to the royal medical colleges in the United Kingdom and their faculties death of the brain stem is a component of brain death, and brain death is death.1 The criteria for brain stem death are well established,2 and their use in intensive care units enables treatment to be withdrawn from patients with brain stem death without recourse to the courts. Conversely, as a result of several high profile cases, persistent vegetative state has been reported on frequently in recent years. The application to the High Court in 1992 to discontinue life sustaining treatment for Tony Bland, who had been injured in the tragedy at Hillsborough football ground, brought the ethical debate to the front pages of the national press. Occasional stories of “miraculous recoveries” from comas are widely reported and may have led to an exaggeration of the small chances that patients have of recovering from a persistent vegetative state among a public that is increasingly well versed in this condition. This contrasts with the inevitable death from asystole which occurs within a few days for patients who are brain dead.3

We have experienced a case in which, although the patient had been declared brain stem dead, the patient's family prevented us from switching off the ventilator. On this occasion our intensive care unit was full, and maintaining this patient on a ventilator might have forced us to transfer any new …