Rehabilitation Organization Clarifies Clinical Distinctions Between the Vegetative and Minimally Conscious States

10/28/2003

From: John Whyte, MD, PhD, 215-456-5924, e-mail: jwhyte@einstein.edu; Joseph Giacino, PhD, 732-906-2640, e-mail: jgiacino@solaris.org, both for the American Congress of Rehabilitation Medicine

INDIANAPOLIS, Oct. 28 -- Following is a statement of the American Congress of Rehabilitation Medicine:

We regret the prolonged and painful conflict among the family members of Terri Schiavo, that has resulted from disagreements about whether to withdraw the delivery of food and fluids by tube. We have also been dismayed by the amount of confusion and misinformation among the media and the general public about the tragic conditions of the vegetative and minimally conscious states that sometimes follow severe brain injury.

We are writing on behalf of the American Congress of Rehabilitation Medicine, a multidisciplinary group of rehabilitation professionals involved in clinical care and research including individuals with severe brain damage, in the hope that we can help provide a more accurate understanding of some of the complex issues involved in the case.

After severe brain injury, some individuals remain unconscious for long periods of time. In true coma, the person's eyes remain closed and there is little or no spontaneous movement. Individuals either recover consciousness or evolve into the vegetative state within 4 weeks. In the vegetative state, the eyes are open and there is some degree of spontaneous movement, but there is no evidence that this movement is purposefully related to the surrounding environment. In the minimally conscious state, there is inconsistent but definite behavioral evidence of conscious awareness.

Critical decisions in this context typically revolve around the individual's current state of consciousness and their potential for further recovery. In order to clarify these issues, it is imperative that the individual be carefully assessed by professionals skilled in distinguishing between the vegetative and minimally conscious states and evaluating prognosis.

Although the critical boundary between the vegetative and minimally conscious states is clear in principle, making an accurate diagnosis is difficult and prone to errors in both directions. At least three published studies have shown that a high proportion of individuals diagnosed as vegetative proved to be minimally conscious when examined by skilled specialists. Conversely, it is common for family members and clinicians to interpret certain behaviors, such as smiling, as evidence of consciousness when, in fact, these behaviors may be the result of reflexive or automatic processes of the brain. The accurate interpretation of such behaviors rests on determining whether or not they occur more often in appropriate situations than in irrelevant ones-for example, whether a "smile" occurs more often following a pleasant greeting from a family member than it does after a loud noise. An accurate diagnosis requires repeated evaluations over a period of time to establish this relationship.

Both the vegetative and minimally conscious states can be temporary stages on the path to recovery or permanent states, and in both cases, the longer the individual remains in these states, the lower the odds of substantial improvement in the future. Significant recovery many years after injury is extremely rare.

When important clinical, legal, or ethical decisions depend on the individual's state of consciousness and prognosis, we believe that it is imperative that such individuals receive repeated assessments designed specifically for individuals who are unable to communicate independently. Further, these assessments should be conducted by specialists skilled in this process.