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Patients with prolonged disorders of consciousness: more than a clinical challenge
  1. Derick Wade
  1. Correspondence to Dr Derick Wade, Oxford Centre for Enablement, Windmill Road, Oxford OX3 7HE, UK; derick.wade{at}{at}

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We can now not only postpone death but we can prolong death. Moribund people may be kept alive for hours or days, until support is withdrawn or death inevitably occurs. One situation, brainstem death, is now regarded in law as death, even though the heart is beating.

Patients in the permanent vegetative state are as dead as those who are brainstem dead. They have no awareness—no experience of life or social interaction—and they will eventually die without regaining any autonomy. The differences are that (A) this situation has not (yet) been legally defined as death, (B) the diagnosis is not so categorically and easily determined and (C) the process of death may extend for many years.

The management of patients with prolonged disorders of consciousness, including the permanent vegetative state, is challenging because of the uncertainties about diagnosis (eg, can we know that someone is unaware?) and prognosis (eg, can we be certain that recovery will not occur?). Clinical staff and managers often take the easy option—just continue treatment—because it is much less challenging. But is that correct?

New guidance on prolonged disorders of consciousness from …

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  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed. This paper was reviewed by Adam Zeman, Exeter, UK.

  • Relevant interests I was a co-chair on the recent Royal College of Physicians Working party that drew up the Third Edition of Guidelines. I have undertaken and continue to undertake medico-legal assessments and reports on people with prolonged disorders of consciousness, including reports on patients whose cases are going to court for permission to withdraw Clinically Assisted Nutrition and Hydration. My NHS Trust admits such patients for assessment and management.

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