From the Guidelines
Patients in a vegetative state should be given artificial nutrition and hydration in cases of uncertain prognosis, as stated in the ESPEN guideline 1. This approach is based on the principle of providing care when the outcome is uncertain, emphasizing the importance of nutrition and hydration in supporting the patient's basic needs. The definition of a persistent vegetative state, as an unconscious state after severe brain injury lasting longer than a few weeks, underscores the complexity of managing such patients 1. Key considerations in managing patients in a vegetative state include:
- Providing artificial nutrition and hydration, especially when the prognosis is uncertain 1
- Evaluating the potential for recovery, which is extremely unlikely after one year in posttraumatic cases and after three months in non-traumatic cases 1
- Considering the patient's advance directive or presumed will once the diagnosis of persistent vegetative state is established 1
- Focusing on preventing complications through proper care, including skin care, physical therapy, and management of bodily functions. The ethical aspects of care for patients in a vegetative state are multifaceted, involving discussions about life-sustaining treatments and the patient's previously expressed wishes when possible 1.
From the Research
Definition and Management of Vegetative State
- The vegetative state is a condition characterized by a lack of awareness and responsiveness, with patients often requiring long-term management and care 2.
- The management of patients in a vegetative state poses several challenges, including deciding whether tube feeding is treatment or nutritional care, and determining the patient's quality of life 2.
Clinical Presentations and Treatment Options
- The neuropathology of the vegetative state and the pathophysiology of spasticity are complex, and current treatment options include physical, pharmacological, and surgical interventions 3.
- A multimodal approach to treatment is likely to be the most effective, and knowledge of the likelihood of recovery from the vegetative state can help determine the frequency and intensity of physiotherapy 3.
Ethical Considerations and Decision Making
- Withdrawal of nutrition and hydration is a difficult and sensitive issue, with arguments both for and against the decision to withdraw treatment 4.
- Clinicians must consider the patient's best interests, as well as the views of family and staff, when making decisions about withdrawal of treatment 4.
- The concept of withdrawal of nutrition and hydration is a sensitive issue, and clinicians can expect to be considered as not acting in the patient's best interest whatever decision is taken 4.
Nutrition and Hydration
- Patients in the vegetative state or minimally conscious state often require tube feeding, and nutritional issues particular to these patients include undernourishment, high fluid requirements, bowel management, and vomiting 5.
- Long-term tube feeding can be successful in restoring the patient's body weight to normal limits, but requires careful assessment and monitoring 5.
Treatment of Spasticity
- Oral baclofen is a common treatment for spasticity, but can have adverse effects such as muscle weakness, nausea, somnolence, and paraesthesia 6.
- Intrathecal baclofen may be an effective alternative to oral baclofen, as it delivers the drug directly into the cerebrospinal fluid, minimizing side effects 6.