We here present a new name (
unresponsive wakefulness syndrome or UWS) for an over 35-year-old syndrome with an unintended albeit persistent negative connotation: the vegetative state. The widespread use of intensive care medicine and artificial ventilation to sustain respiration and circulation has increased survival from coma. It has also led to an increasing number of patients who have
awakened from coma (that is, showed eye opening, incompatible with the diagnosis of coma) yet remain unresponsive (that is, only showed reflex movements as is also the case for coma) [
1]. In Europe, this clinical syndrome was initially termed
apallic syndrome [
2] and
coma vigil [
3] but it is currently known in the medical community as
persistent vegetative state (PVS), a term first coined by Jennet and Plum in 1972 in their milestone
Lancet paper [
4]. The name
vegetative state was chosen to refer to the preserved vegetative nervous functioning, meaning these patients have (variably) preserved sleep-wake cycles, respiration, digestion or thermoregulation. The term
persistent was added to denote that the condition remained for at least one month after insult. In 1994, the Multi-Society Task Force on PVS defined the temporal criteria for irreversibility (that is, more than one year for traumatic and three months for non-traumatic (anoxic) etiology) and introduced the notion of
permanent vegetative state [
5]. It is to these latter cases that ethical and legal end-of-life issues, of withholding and withdrawal of life sustaining treatment (that is, artificial hydration and nutrition), are related [
6,
7].
Over the last three decades, a growing number of physicians and healthcare workers have felt uncomfortable when referring to patients as
vegetative [
8‐
10], resulting in a number of papers reiterating the intellectual justification of the origins and choice of the term [
11]. The conception of a
vegetative nervous system goes back to 1800 when Bichat divided the nervous system into animalic and vegetative [
12]. The former linked the person to her or his environment and was expressed by the muscles of voluntary locomotion and the organs of external senses. The latter identified the nutritional functions of the body. According to the Oxford English dictionary, '
to vegetate' is to 'live a merely physical life devoid of intellectual activity or social intercourse' and '
vegetative' describes 'an organic body capable of growth and development but devoid of sensation and thought'. To part, if not most, of the lay public and media, however, it has a rather pejorative undertone and seems (incorrectly) to refer to patients as being
vegetable-like (for example, an internet search with the terms
vegetative state and
vegetable returned 26,700 hits,
état végétatif and
plante 19,600;
stato vegetativo and
vegetale 49,100 (Google search performed 8 April 2010). Many authors and social, political and religious groups have hence felt the need to emphasize these patients' clearly evident rights to be fully regarded as human beings [
13,
14].
In addition to this malaise regarding the chosen term and its unintended denigrating connotation, some feel that referring to these patients as being in a
state may (incorrectly) denote chronicity. Despite the fact that the clinical criteria of the vegetative state do not imply a temporal dimension, referring only to a clinical tableau reflecting
wakeful unawareness [
4], for many physicians and healthcare workers it has the negative connotation of a being a longstanding and nearly irreversible condition. The introduction of the term
persistent vegetative state (too often confounded with
permanent vegetative state with which it unfortunately shares the same abbreviation PVS), may have contributed to this [
15]. In contrast to coma (which is an acute and transitory condition, lasting no more than days or weeks), a
vegetative state may become chronic (lasting for decades) or may remain a transitory condition on the way to further recovery [
16]. This recently led the
Aspen Neurobehavioral Conference Workgroup to characterize a new clinical entity coined the 'minimally conscious state' (MCS), describing patients who have recovered from a
vegetative state (meaning they show more than reflex motor behavior but fail to show functional communication or object use) [
17]. Despite clear evidence that
vegetative patients are not uniformly hopeless [
18,
19], once stamped with the diagnosis
VS, clinical practice shows it often is difficult to change the label, and the first signs of recovery of consciousness are too often missed. Previous studies by Childs
et al. in Texas [
20] and Andrews
et al. in London [
21] have estimated misdiagnosis of chronic patients referred to rehabilitation centers to be at around 40%. It has been argued that these older studies, performed prior to the publication of the Multi-Society Task Force on PVS criteria [
5] of VS, and long before the criteria of the MCS [
17], were overly pessimistic. A very recent study, however, confirmed this unacceptably high rate of diagnostic error [
22]. A number of highly publicised patients also illustrate this point. Julia Tavalaro survived a brain trauma and was transferred to a tertiary care centre where she was called "
the vegetable" for over six years, although she was conscious and sensate. She later wrote her memoirs in
Look Up for Yes [
23]. Terry Wallis, who was considered to be in a VS, made the headlines when he started to speak 19 years after his car accident. Careful analysis of his medical records quickly showed he actually recovered to a MCS within the first year after his brain trauma [
24]. Finally, since the term VS was coined in 1972, an increasing number of functional neuroimaging and event related potential (ERP) studies have shown that physicians should be very careful about making strong claims about patients' awareness [
25‐
31]. This situation is further complicated when patients with such disorders of consciousness have underlying deficits in the domain of verbal or non-verbal communication functions, such as aphasia, agnosia or apraxia [
32,
33].