[Vegetative state. Practice guideline for its diagnosis and treatment]

Vegetative state (VS) is a clinical condition in which patients have lost both their consciousness content and alertness. So defined, it seems a simple diagnosis to achieve. However, facts disprove this idea, and indeed a striking evidence exists that doctors are unable to satisfactorily diagnose VS. In this series of 3 articles, a multi-disciplinary Italian working group proposes solutions in order to properly diagnose VS (Part I) and to differentiate it from other apparently similar situations (part II). Consciousness, coma and VS state are clearly defined and the reader is provided with easy-to-use methods to achieve the goal. Differential diagnosis includes the locked-in syndrome, the akinetic mutism, and the minimally conscious state, this latter being a challenging situation, which deserves great reader's attention. In the last part the authors afford the delicate argument on when and how a VS can be defined as permanent. Modern research on the use of magnetic resonance imaging in trauma patients and evoked potentials in anoxic patients are presented, and a flow-chart rationalizes the process of outcome prediction. Rehabilitation programs are also indicated to facilitate the continuum of care from the acute to post-acute phase. Lastly, the authors propose the problem of whether interventions are worth doing in such an extremely disabled population. No definite answers are given, and question remains open to discussion. It could not have been that so: doctors cannot be the only judge when a life worth living or not is to be sentenced.