Assessment After Extremely Severe Head Injury in a Case of Life or Death: Further Support for McMillan.

1. Shiel & B. A. Wilson, Assessment After Extremely Severe Head Injury in a Case of Life or Death: Further Support for McMillan, 12 BRAIN INJURY 809 (1998).

Assessment of people with multiple injury is problematic particularly when it is not clear what the subject's response level may be. Distinguishing between those who are vegetative and those who could be described as minimally responsive is not easy. At present the diagnosis of vegetative state is given inordinate emphasis, not least because many decisions regarding continued treatment appear to be made on the basis of diagnosis. Misdiagnosis, however, appears to be more common than expected. In a study of subjects diagnosed as being vegetative Childs found that diagnosis was incorrect in 37% of cases. More recently, Andrews noted similar findings with patients admitted to his unit. Rosenberg and Ashwal suggested the following distinctions between subjects who are in coma, vegetative or minimally responsive. Patients in coma [appear to] have no self awareness, are not aware of pain, do not have sleep-wake cycles or purposeful movement and may have depressed respiratory functions. Coma [usuallyl evolves over a 2-4 week period into consciousness, the vegetative state or death. Subjects in the vegetative state [appear to] have no self-awareness, do not feel pain, have sleep-wake cycles, have no purposeful movement and have normal respiratory function. Minimally responsive patients differ in so far as they have limited self awareness, do feel pain and have sleep-wake cycles. They may also have severely limited movement and respiratory function may be depressed.

McMillan described an assessment procedure for an extremely severely head injured patient, which involved a series of yes/no questions which were answered by the patient pressing a red button designed by the Medical Physics department, and the results of the assessment. Data were analyzed for each set of questions using binomial tests and the results suggested that the patient was sentient, was not vegetative and, at the time of testing, wanted to live. This article describes a subsequent assessment with the same patient using similar but not identical methodology and presents findings in relation to those of McMillan.

To establish the patient's ability to respond accurately, ten autobiographical questions were asked in random order across six trials. The patient gave a 100% correct response on four trials, and a 90% correct...