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Permanent loss of awareness is crucial to diagnosis of PVS

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7406.67 (Published 10 July 2003) Cite this as: BMJ 2003;327:67

Rapid Response:

Vegetative State: term should be changed

As a Fellow of the Royal College of Physicians (RCP) I was delighted
to receive the recent report of the RCP (1) working party on the
"vegetative state", reviewed by Clare Dyer (2).

There is much confusion about the use and misuse of the terms
"persistent vegetative state", "permanent vegetative state", "coma
depasse", and “coma vigil". The report is helpful in providing conceptual
and operational definitions of "persistent vegetative state", "permanent
vegetative state" (PVS), "minimally conscious state" (MCS) and “coma”.

However, "PVS" will continue to be used as an abbreviation for both
"persistent vegetative state" and "permanent vegetative state (PVS)" and
for professional reasons therefore new terms should be developed to avoid
potentially grave errors.

More importantly, it is imperative, in the wake of the Bristol and
Alder Hey enquiries, that all medical activities are open to patient and
public scrutiny and that the words we use are not offensive. A statement
defining the medical use of "vegetative state" is not enough to avoid
offence.

Whatever the technical definition of a word it may also carry other,
sometimes emotive, connotations. "Vegetative" derives from a reference to
vital organ function apart from the Central Nervous System, however it can
so easily be heard as "vegetable". "The doctor said he was a vegetable",
recounted to me by several tearful relatives is a distressing but
avoidable misunderstanding.

The term "vegetative state" will always be dehumanising and
insulting. The medical language we use and should share with patients,
their families and friends, should not be dehumanising or insulting. The
Alder Hey enquiry has shown that even the deceased should be respected and
potentially dehumanising behaviour avoided. Terms such as “mongolism” and
“happy puppet syndrome” have been replaced with Down syndrome and Angelman
syndrome for this very reason.

I suggest that we keep the conceptual and operational definitions for
"vegetative state", "persistent vegetative state" and "permanent
vegetative state (PVS)" but change the terms to reflect the core concept
of being unaware. We can use the term "unaware" in place of "vegetative";
its common meaning being close to the medical concept of "vegetative
state"(1, 2). "Vegetative state", "persistent vegetative state" and
"permanent vegetative state (PVS)" would become "unaware state", "chronic
unaware state (CUS)" and "permanent unaware state (PUS)".

An evidence base to support the change in terms, if one were needed,
could be sought from a survey of patients who had made good functional
recovery from coma and their relatives. It is perhaps surprising that, up
to now, most doctors and medical journal editors have been content to
continue with their "vegetative" states.

References

1. Royal College of Physicians. The vegetative state: guidance on
diagnosis and management. Clin Med 2003;3:249-54.

Dyer C. Permanent loss of awareness is crucial to diagnosis of PVS. BMJ
2003;327:67.

Competing interests:  
None declared

Competing interests: No competing interests

16 July 2003
William P Whitehouse
Senior Lecturer in Paediatric Neurology
University of Nottingham NG7 2UH