People Wiith Severe Spinal Cord Injury Continue to Produce Normal Activity in the Motor

A vegetative state occurs when the cerebrum (the part of the brain that controls thought and behavior) no longer functions, but the hypothalamus and brain stem (the parts of the brain that control vital functions, such as sleep cycles, body temperature, breathing, blood pressure, heart rate, and consciousness) continue to function. Thus, people open their eyes and appear awake but otherwise do not respond to stimulation in any meaningful way.

• Most commonly, a vegetative state is caused by severe brain damage due to a head injury or a disorder that deprives the brain of oxygen, such as cardiac or respiratory arrest.

• People in a vegetative state can open their eyes, but they cannot speak or do things that require thought or conscious intention, and they have no awareness of themselves or their environment.

• Doctors diagnose a vegetative state only after they observe people for a period of time and on more than one occasion and do not find any evidence of awareness.

• People in a vegetative state require comprehensive care, including good nutrition and measures to prevent problems that result from not being able to move (such as pressure sores).

The vegetative state is rare.

How many people are in a vegetative state is unknown, but about 25,000 adults and almost 10,000 children in the United States are thought to have this disorder.

Most commonly, a vegetative state is caused by severe brain damage due to

People in a vegetative state can do some things because some parts of the brain are functioning:

• They can open their eyes.

• They have relatively regular sleeping and waking patterns (but not necessarily related to day and night).

• They can breathe, suck, chew, cough, gag, swallow, and make guttural sounds.

• They may even be startled by loud noises and appear to smile or frown.

Because of these responses, they may appear to be aware of their surroundings. However, they have no awareness of themselves or their environment. Their apparent responses to their surroundings result from automatic (involuntary) basic reflexes and not from a conscious action. For example, they may instinctively grasp an object when it touches their hand, as a baby does.

People in a vegetative state cannot do things that require thought or conscious intention. They cannot speak, follow commands, move their limbs purposefully, or move to avoid a painful stimulus.

People in a vegetative state have no control over urination and bowel movements (are incontinent).

• A doctor's evaluation

• Tests such as magnetic resonance imaging and electroencephalography

Some people spontaneously recover from a vegetative state, but recovery is usually incomplete. The chances of recovery depend on the cause and extent of the brain damage and the person's age, as for the following:

• Some recovery is more likely if the cause is a head injury, a reversible metabolic abnormality (such as low blood sugar), or a drug overdose rather than a major stroke or cardiac arrest.

• Younger people may recover more use of their muscles than older people, but differences in recovery of mental function, behavior, and speech are not significant.

• If a vegetative state lasts for more than a few months, people are unlikely to recover consciousness. If people do recover, they are likely to be severely disabled.

Any recovery from a vegetative state is unlikely after 1 month if the cause was anything other than a head injury. If the cause was a head injury, recovery is unlikely after 12 months. However, a few people improve over a period of months or years. Rarely, improvement occurs late. After 5 years, about 3% of people recover the ability to communicate and understand, but few can live independently, and none can function normally.

Most people who remain in a vegetative state die within 6 months of the original brain damage. Most of the others live about 2 to 5 years. The cause of death is often a respiratory or urinary tract infection or severe malfunction (failure) of several organs. But death may occur suddenly, and the cause may be unknown. A few people live for several years.

There have been reports of people regaining some awareness after spending years in what appears to be in a vegetative state or coma. These reports often involve people who had been in a minimally conscious state, usually after a head injury. Chances of recovery from a minimally conscious state are unpredictable but better than those from a vegetative state.

• Preventive measures for problems due to immobilization

• Good nutrition

Music therapy may have slight beneficial effects by stimulating a response in people in a vegetative state or other types of impaired consciousness. But the usefulness of this therapy is as yet unclear.

• Contractures: Lack of movement can also lead to permanent stiffening and shortening of muscles (contractures) causing joints to become permanently bent.

Pressure sores can be prevented by frequently repositioning the person and placing protective padding under parts of the body that are in contact with the bed, such as the heels, to protect them.

To prevent contractures, physical therapists gently move the person's joints in all directions (passive range-of-motion exercises) or splint joints in certain positions.

Because people are incontinent, care should be taken to keep the skin clean and dry. If the bladder is not functioning and urine is being retained, a tube (catheter) may be placed in the bladder to drain urine. Catheters are carefully cleaned and regularly examined to prevent urinary tract infections from developing.

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