title: The vegetative state: prevalence, misdiagnosis, and treatment limitations.
abstract: BACKGROUND
  Patients in a vegetative state/unresponsive wakefulness syndrome (VS/UWS) open their eyes spontaneously, but show only reflexive behavior. Although VS/UWS is one of the worst possible outcomes of acquired brain injury, its prevalence is largely unknown. This study's objective was to map the total population of hospitalized and institutionalized patients in VS/UWS in the Netherlands: prevalence, clinical characteristics, and treatment limitations.
  
  
  METHODS
  Nationwide point prevalence study on patients in VS/UWS at least 1 month after acute brain injury in hospitals, rehabilitation centers, nursing homes, institutions for people with intellectual disability, and hospices; diagnosis verification by a researcher using the Coma Recovery Scale-revised (CRS-r); gathering of demographics, clinical characteristics, and treatment limitations.
  
  
  RESULTS
  We identified 33 patients in VS/UWS, 24 of whose diagnoses could be verified. Patients were on average 51 years old with a mean duration of VS/UWS of 5 years. The main etiology was hypoxia sustained during cardiac arrest and resuscitation. More than 50% of patients had not received rehabilitation services. Most were given life-sustaining treatment beyond internationally accepted prognostic boundaries regarding recovery of consciousness. Seventeen (39%) of 41 patients presumed to be in VS/UWS were found to be at least minimally conscious.
  
  
  CONCLUSIONS
  Results translate to a prevalence of 0.1 to 0.2 hospitalized and institutionalized VS/UWS patients per 100,000 members of the general population. This small figure may be related to the legal option to withhold or withdraw life-sustaining treatment, including artificial nutrition and hydration. On the other hand, this study shows that in certain cases, physicians continue life-prolonging treatment for up to 25 years. Patients have poor access to rehabilitation and are at substantial risk for misdiagnosis.
authors.affiliation: Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Liège, Belgium. Electronic address: willemijn.vanerp@radboudumc.nl.
authors.forename: Willemijn S
authors.initials: WS
authors.lastname: van Erp
authors.affiliation: Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands.
authors.forename: Jan C M
authors.initials: JC
authors.lastname: Lavrijsen
authors.affiliation: Department of Neurology, Singeland Ziekenhuis, Doetinchem, The Netherlands.
authors.forename: Pieter E
authors.initials: PE
authors.lastname: Vos
authors.affiliation: Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands.
authors.forename: Hans
authors.initials: H
authors.lastname: Bor
authors.affiliation: Coma Science Group, Cyclotron Research Center and Neurology Department, University of Liège, Liège, Belgium; University Hospital of Liège, Liège, Belgium; Belgian Funds for Scientific Research, Belgium.
authors.forename: Steven
authors.initials: S
authors.lastname: Laureys
authors.affiliation: Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Medical Centre, Nijmegen, The Netherlands; Waalboog Foundation, Joachim and Anna, Centre for Specialised Geriatric Care, Nijmegen, The Netherlands.
authors.forename: Raymond T C M
authors.initials: RT
authors.lastname: Koopmans
mesh_terms: D000328:Adult; D000368:Aged; D003937:Diagnosis, Differential; D005260:Female; D006738:Hospices; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D009735:Nursing Homes; D018458:Persistent Vegetative State / Q000175:diagnosis* / Q000453:epidemiology* / Q000534:rehabilitation*; D015995:Prevalence; D012047:Rehabilitation Centers
keywords: Long-term care; acquired brain injury; ethics; rehabilitation; vegetative state