“We believe your father is in a vegetative state”. “You mean he is a vegetable? He never wanted that”

The hair-raising opinion article by Langlume et al. [1] includes an anecdote of a junior physician’s appallingly tactless conversation with a family member about the outcome of prolonged coma using the word “vegetable.”

The authors warn against the use of metaphors in Medicine, and I second their concern.

I would like to add contextualization and a little history. Annas [2] pointed out a proclivity in the US to use military terms, but “war on cancer” was first used in the British Medical Journal in 1904. The recent pandemic has seen military metaphors including “frontline” workers,” “at war with Covid-19,” and “retired nursing staff redeployed.” Phrases such as “I am fighting for the patient,” are inaccurate and self-aggrandizing. (Does a bad outcome mean we did not try hard enough?) Families recognize pontification. These terms from popular culture should have no place inside the walls of a hospital. Likewise, the term “vegetative state” has been associated with “vegetable” but typically by families and other laypersons; it should never be used by physicians or other health care providers. Many European practitioners use the word “plant,” which is equally dismissive and disrespectful. “Vegetable” or “plant” is not a metaphor but an erroneous conjecture.

The comatose patients in question have transitioned to a clinical state resulting in unaware, open-eyed awake-and-sleep cycles. This clinical syndrome—named persistent vegetative state (PVS) in the early 1970s—described patients without evidence of a functioning mind [3]. More recently, this state has also been called “unresponsiveness wakefulness syndrome,” again because of the alleged negative connotation of the word “vegetative,” in PVS, which, the authors suggest, invites the use of the word “vegetable” [4]. This term is closer to the older term coma vigile (from vigilance), which was equally undescriptive but anatomically more diversified than Kretschmer’s das apallischen syndrome pointing out the destruction of the cortical mantle. Jouvet introduced the term “la stupeur hypertonique post-comateuse” to indicate little more than increased tone. French neurologists also proposed vie vegetative or coma prolongé. I still insist there is no need to discredit Jennett and Plum’s original, carefully chosen, reasoned term persistent vegetative state; replacing it only promotes confusion [5].We can endlessly debate the adjective. “Vegetative” describes the viscerally autonomous homeostasis of a body but no working mind. Plum noted that he could have called it “persistent autonomic state” but felt that it was less accomodating. Putting the point most basically, vegetative state is a term that families, our hospital colleagues, and any other professional can understand. Families know what a vegetative state means, although their understanding of this joyless and devastating existence is broader and includes any uncommunicative patient requiring full, extensive, and prolonged nursing home care.

Metaphors for coma descend into absurdism and should be avoided. Moreover, the diagnosis—which requires a prolonged focus of clinical attention—is rarely cemented in acute intensive care settings. There are delicate questions hovering over the entrenched nature of the diagnosis of PVS. Whether future brain function studies will consistently find clinically relevant shortcomings is unestablished; all the more reason to be tentative and self-critical.

References

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Wijdicks, E. “We believe your father is in a vegetative state”. “You mean he is a vegetable? He never wanted that”. Intensive Care Med (2021). https://doi.org/10.1007/s00134-020-06332-8

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