Vegetative patients should die, say doctors

The overwhelming majority of doctors who treat patients in the deep, coma-like state known as persistent vegetative state (PVS), believe that treatment should be withheld in some circumstances to allow patients to die.

In the first comprehensive survey of more than 1,000 neurologists, neurosurgeons and other specialists, there was more than 90 per cent support for not treating acute infections and other life-threatening conditions in PVS patients where "appropriate."

The survey, by the Centre of Medical Law and Ethics at King's College London, reveals widespread discrepancies in hospital policy and in the medical care of PVS patients.

The researchers call on the Government to act urgently to collate information on PVS patients in UK hospitals, how they are treated and by whom, and to formalise guidelines on their care.

Almost 75 per cent of doctors surveyed said it can "sometimes" be appropriate to withdraw artificial feeding and hydration from such patients. Contrary to advice given by the British Medical Association, a majority of doctors said that withdrawal of artificial nutrition and hydration could be considered within a year of PVS diagnosis.

More than a third said it would be appropriate to consider withdrawal after the patient had been in PVS for six months.

The findings of the survey conflict with BMA advice that treatment-limiting decisions should not be considered until the patient has been in PVS for a year or more.

PVS is used to describe patients with severe brain damage who spend time awake and asleep; who show no meaningful response to things around them, and whose movements and reactions are reflex. They can breathe on their own but most have to be fed through a tube.

It is estimated that there are between 1,000 and 1,500 PVS patients in the UK, and since the 1993 High Court case of Hillsborough victim, Tony Bland, the condition has been the focus of much public debate.

There have now been nine cases in England since Bland, when the courts have approved withdrawal of life-sustaining measures from PVS patients. The most controversial cases have centred on withdrawal of food and water.

There has also been public concern about misdiagnosis of PVS after a study published last year found that 17 patients diagnosed as PVS were in fact aware of themselves and their surroundings, and could communicate in limited ways with their carers and families.

This raises the possibility that people from whom treatment, food and water were withdrawn, and allowed to die, were not in PVS.

The survey, which attracted 1,027 respondents also found that three-quarters disagreed with court involvement in PVS cases, although a similar proportion agreed with the Bland decision to allow him to die.

However, doctors still appear reluctant to give weight to an advance directive made by patients in decisions about withdrawing artificial nutrition and hydration, the survey revealed.

Pat Walsh, acting director of the Centre of Medical Law and Ethics said; "There is a pressing need for further research to unpack the implicit moral reasoning behind what doctors are doing."

Doctors' views on the management of patients in persistent vegetative state (PVS): a UK study, is available from the Centre of Medical Law and Ethics, King's College, London. Tel: 0171 873 2382.