Medical decision making in the vegetative state: withdrawal of nutrition and hydration

Withdrawal of nutrition and hydration, is a difficult and sensitive issue for all those working with people in the vegetative state. There are arguments against the decision to withdraw any treatment that might result in the patient deteriorating or dying. These arguments include the view that all life is worth having, that we can never be certain that the patient is not aware, and concerns that there may be new scientific developments in the future from which the patient would benefit. Others argue that the patient has no interests in life; that it is undignified, if not an assault, to insert tubes into a permanently unconscious person; that very few people would want to survive in this condition; and that it prevents loves ones from grieving. These strongly held opposing views can make clinical decision making very difficult for the clinician. Once the decision has been made to withdraw treatment then the clinician has to be certain that the patient is in the vegetative state, that there are no factors preventing the patient demonstrating awareness, that he has received expert assessment and treatment, and that the prognosis for lack of recovery is as clear as it can be. It is important to support family and staff throughout this process. The concept of withdrawal of nutrition and hydration is a sensitive issue and clinicians can expect to be considered as not acting in the patient's best interest whatever decision is taken.