Module 2: Portraying Patients
2.3 Vegetative versus Coma
Definitions and the precision of words we use are very important whatever the topic. Words carry assumptions, memories and associations. They can be specific and help clear thinking or they conflate different things together making it hard to navigate a more precise understanding. They can promote stigma and negative associations, or invite empathy or different types of imaginigs. In this unit we explore this in relation to the words ‘coma’ and ‘vegetative’ and introduce the clinical distinction between the two diagnoses.
The word ‘vegetative’ is disliked by many people because of the association with calling someone ‘a vegetable’, in some countries clinicians have adopted an alternative label: ‘unresponsive wakefulness syndromes’. Families also often make conscious choices about what terms to use about their relative. Sometimes the word ‘coma’ is preferred. One woman for example, said she preferred to talk of her son as being ‘in a coma’ rather than being vegetative, or profoundly brain damaged, because she felt it was less stigmatising, and preserved a sense of hope for awakening. Another person we spoke with, however, commented that he preferred to use the term ‘vegetative’ rather than ‘coma’ about his mother’s condition because he felt it was more ‘realistic’. He felt that the word ‘vegetative’ helped avoid some misconceptions that can occur when people think about coma.
Short term versus long term unconsciousness: A problem with media representation and everyday conversation is that the term ‘coma’ is used to cover a broad spectrum of quite different conditions. Journalists write about people slipping into a coma before they die, or being rushed unconscious to intensive care, or being in a ‘medically induced’ coma for a few days or weeks before they recover. Famous people who have been in such comas, but are then living proof of recovery include actors such as Sharon Stone or Michelle Hurst, musicians such as Ozzy Osbourne or Stevie Wonder and the stunt performer, Evel Kenievel.
When people hear the word ‘coma’ they often imagine the anxious bedside vigil waiting for the patient to open their eyes, the sounds of the ventilator and the bleep of a heart monitor. Such scenes are common in medical drama and in hospital reality-TV (and a significant proportion of the population will have also had personal experience of this).
Short term comas however, are very different from the long-term condition of being unconscious. If patients continue in an unconscious state for a very long time this is usually a sign of catastrophic brain injury and has a distinct clinical diagnosis. This is when doctors will assign the label: ‘the vegetative state’. These patients do not remain in intensive care, they do not usually reside in hospital or need high-tech interventions such as a ventilator. They are moved (often after a trial in specialist rehabilition centres) into long term nursing facilities, care homes or even into their own family homes. Their chances of ever regaining consciousness diminish over time.
So, when celebrities, sports personalities or politicians are described as remaining in a state of unconsciousness for months or years; they are probably not technically in a ‘coma’, they may be in a vegetative state (or some other type of prolonged disorder of consciousness).
What is the difference between ‘coma’ and ‘vegetative state’ as a clinical diagnosis? Click on the tabs above for summary definitions.
It’s very unusual for a coma to last more than a few weeks at most. People in a coma are completely unresponsive. They do not move, or react to sound. Their eyes are closed. The brain responds to extreme trauma by effectively ‘shutting down’. Some scientists compare it to being under a general anaesthetic. Sometimes patients with very severe brain injuries who do not enter a coma naturally are placed in a medically-induced coma (using a drug like propofol which is used in anaesthesia) to try to allow the brain time to heal. If they have only been in a coma for a few days they may ‘wake up’ to full consciousness with relatively little damage. If the person has very severe brain injuries though, they may move from coma into a vegetative state.
A person who is VEGETATIVE has been unconscious for at least a few weeks – and this usually a sign of severe brain injuries. They are unaware of themselves or their environment but, unlike someone in a coma, the patient has sleep-wake cycles in which their eyes are open for periods of time and they may even smile or cry. They will probably be able to breathe on their own (most are not dependent on a ventilator long-term). They remain entirely dependent on 24/7 care (e.g. clinically assisted nutrition and hydration, turning regularly to stop bed sores, suctioning if necessary etc).
In this course we often use the term vegetative state in order to be clear about the distinction between this and short periods of unconsciousness. We recognise that some people don’t like the term ‘vegetative’ but we think it is important for clarity. Family members and academics we quote don’t always follow this distinction, so when quoting them the term coma will be used sometimes. You’ll also sometimes hear reference to ‘minimally conscious state’ which is another prolonged disorder of consciousness (which you’ll learn more about later in this course).
Answer the quick quiz below to check your knowledge of the vegetative state.
Look at the picture you drew of someone in a vegetative state. Are there machines in the picture such as a heart monitor or ventilator? Did you imagine the patient being cared for in a hospital setting?
Go to ‘Google Images’ and search on ‘coma’, scan the strap lines below the images, can you see examples where the correct term was probably ‘vegetative’ not ‘coma. Now search on ‘vegetative state’. Does this searches generate some overlapping and some different types of images (e.g. in general do you see less medical equipment in the ‘vegetative’ search).
Before reading the information above were you clear about the differences between a short coma and a long-term vegetative state? Does the distinction matter? You might want to add a comment to the section at the very bottom of this page or have a look at what other people have said.