Protocols for the vegetative state.

The diagnosis of the vegetative state, the fate worse than death, brings with it a nihilistic approach to the patient, untold misery to the family, emotional turmoil to medical and nursing staff who work in brain injury units and enormous economic cost to the country. There are no protocols yet devised for the vegetative state. The diagnosis has been shown to be incorrectly applied in a significant number of patients. The ethics of the situation needs full exploration. This paper explores the practical aspects of the diagnosis and management of the vegetative state and present methods of resolving problems associated with them.

Community-based rehabilitation of the person with a severe brain injury.

Community-based rehabilitation (CBR) recognizes that in the secure, loving environment of his/her own home, the person with a brain injury and the family, provided with support and guidance, can effectively augment or supersede hospital-based rehabilitation. This paper will explore the methods used to establish a rehabilitation programme in the home, the initial moves, the family dynamics, the advantages, and some of the programmes required for the restoration of function of sensory, cognitive and motor abilities. The mobilization of the therapy workforce, including the use of extended family and trained volunteers from the community, is explained. The importance of volunteer meetings and the continuing education of the family and volunteers is emphasized. Respite care for the family and the aim of returning the family towards normality is considered. The enormous cost/benefit of the community-based rehabilitation is detailed, and comparative costs between this method and hospital-based rehabilitation are provided.

The Coma Exit Chart: assessing the patient in prolonged coma and the vegetative state.

The patient who remains in prolonged coma or in the vegetative state presents major problems in medicine, ethics and resource economics. Diagnosis and decision making are often difficult. A Coma Exit Chart can be developed using the parameters of the Glasgow Coma Scale to measure the exiting of the patient from prolonged coma or the vegetative state.

Severe brain injury: intensive family involvement in community-based rehabilitation.

A 15-year-old boy, severely brain injured as a result of a motor vehicle accident, was in coma for six weeks. Five months after the injury, while still severely disabled, he was taken home and treated by an intensive, organised domiciliary programme of community-based rehabilitation supplemented by additional help from the local hospital. The patient regained function, and the programme was emotionally rewarding for the relatives, friends and volunteers. Significant cost savings to the State may be obtained with this method of management.

Clinical course and outcome of severe head injury in Australia.

The records of 159 severely head-injured patients (all in coma for longer than 6 hours) from Sydney, Australia, were studied. The clinical course, charted over a 2-week period, indicated that 60% of deaths occur by Day 3 and that 12% of patients remain in coma (Glagow Coma Scale (GCS) score less than 7) for more than 2 weeks. Overall, at long-term follow-up review more than 2 years after injury, 51% of patients were dead, 7% were severely disabled or vegetative, and 42% had a good to moderate recovery. Outcome of the patients in prolonged coma was assessed separately, with only one-third making a good or moderate recovery; two-thirds of the severely disabled patients came from this group. The high proportion of poor outcomes associated with prolonged coma suggests that this group of patients should be specifically targeted in research. One appropriate intervention with this group would be the restructuring and intensification of early rehabilitation. However, the GCS score lacks the precision needed for this type of study, and a better measure of recovery should be developed.