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Papers: J C M Lavrijsen, J S G van den Bosch, R T C M Koopmans, and C van Weel Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes J Neurol Neurosurg Psychiatry 2005; 76: 1420-1424 [Abstract] [Full text] [PDF]

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Reply to Stepan et al.

Jan C Lavrijsen, Hans van den Bosch, Raymond Koopmans, Chris van Weel   (14 November 2005)

Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes

Christoph Stepan, Luise Zaunbauer-Haslik, Gerald Haidinger, and Heinrich Binder   (29 September 2005)

Reply to Stepan et al. 14 November 2005
Jan C Lavrijsen, nursing home physician De Zorgboog, Bakel, the Netherlands/Radboud University Nijmegen Medical Centre, Hans van den Bosch, Raymond Koopmans, Chris van Weel Send letter to journal: Re: Reply to Stepan et al. j.lavrijsen{at}vphg.umcn.nl Jan C Lavrijsen, et al.	Dear Editor We thank Dr Stepan and colleagues for their interest in our work.(1) We agree with the possible reasons that they have figured out for the difference between the results of our prevalence study in the Netherlands and their study in Vienna.(2) We confirm that the results remain sizeably different, even if we compare the prevalence of a vegetative state (VS) in all of the nursing homes in our largest city Amsterdam (4/1,000,000) with the results of all of the nursing homes in Vienna (11/1,000,000). We hypothesise that medical decisions to withhold or withdraw medical treatment in previous years may be an explanation for the low prevalence of VS in our study. We have investigated these decisions in Dutch nursing homes, but we agree that it might be important to include hospital data as well for a complete analysis and comparison with other countries. This type of data is not available as far as we know. However, it can be inferred from the literature pertaining to physicians’ attitudes towards end-of-life decisions that withholding or withdrawing futile medical treatment is becoming more practice routine in several countries in Northern Europe.(3) We do not have figures of the attitudes of Austrian physicians in this matter. In our view, different inclusion criteria, different residence groups and different times of investigation could explain the lower prevalence in comparison with the studies by Higashi (Japan) and Ashwal (California). During the last thirty years in the Netherlands, the incidence of traffic accidents resulting in severe brain injury has been reduced by preventive measures, such as the obligation to wear safety belts and helmets.(4) Moreover, it is a known fact that Japanese physicians are very reluctant to abandon life prolongation for patients in a VS.(5) Stephan et al. announced a follow-up of their prevalence study, and we are also planning to repeat our study. This will allow us the opportunity to compare the results of our four studies in more detail in the near future. References 1. Lavrijsen J. Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes. J Neurol Neurosurg Psychiatry 2005;76:1420-24. 2. Stepan C, Haidinger G, Binder H. Prevalence of persistent vegetative state/appalic syndrome in Vienna. European Journal of Neurology 2004;11:461-66. 3. Grubb A, Walsh P, Lambe N. Reporting on the Persistent Vegetative State in Europe. Medical Law Review 1998;6:161-219. 4. Minderhoud JM. Traumatische hersenletsels [traumatic brain injuries]. Houten/Mechelen: Bohn Stafleu van Loghum; 2003. 5. Asai A, Maekawa M, Akiguchi I, Fukui T, Miura Y, Tanabe N, et al. Survey of Japanese physicians' attitudes towards the care of adult patients. Journal of Medical Ethics 1999;25:302-8.
Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes 29 September 2005
Christoph Stepan, Neurologist Neurological Centre Maria-Theresien-Schlössel, Otto Wagner HospitalBaumgartner Höhe 1, 1140 Vienna,, Luise Zaunbauer-Haslik, Gerald Haidinger, and Heinrich Binder Send letter to journal: Re: Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes christoph.stepan{at}wienkav.at Christoph Stepan, et al.	Dear Editor, We read with great interest the paper by Dr. Lavrijsen and colleagues on”Prevalence and characteristics of patients in a vegetative state (VS) in Dutch nursing homes”.[1] They point out that –there is a difference between the prevalence in Vienna and Netherlands (Vienna 19/1 000 000; Netherlands 2/1 000 000).[2] Because of this considerable difference between these two results we would like to figure out possible reasons. First reason seems to be population-related. Lavrijsen and his colleagues recorded only patients with VS in Dutch nursing homes. In our study acute wards as well as nursing homes were included. If we excluded all patients with VS , treated in acute wards, from our data the prevalence of VS for nursing homes in Vienna would be 11/1 000 000. So even after splitting the groups of patients the results differ sizeably. Another difference is that one investigation was in the capitol city of Austria, Vienna (1.620 000 inhabitants) and on the other hand the whole Netherlands (16.200 000). So one survey deals only with an urban population while the other reflects on a mix from urban and rural populations. The second possible reasons from our point of view are the different methods in investigation. Lavrijsen et al. recorded the data from all patients with VS during one month. In Vienna data were recorded within three days, and all patients were assessed by one examiner. In the work of Lavrijsen et al. only in those instances where there were doubts about the diagnosis, one of three examiners assessed the patients. Before comparing such complex data, the differences in health care in patients with VS, beginning from the acute impact to nursing facilities, have to be evaluated. If there is great variability it has to be accounted on in analysis. Lavrijsen results differ not only from our study but also from others, like Higashi (25/1 000 000) and Ashwal (24/1 000 000).[3,4] Therefore it would be very interesting to discuss these differences of results with the authors. References 1. Lavrijsen JCM, vd Bosch JSG, Koopmans RTCM, et al. Prevalence and characteristics of patients in a vegetative state in Durch nursing homes. J Neurol Neurosurg Psychiatry 2005;76:1420-1424. 2. Stepan Ch, Haidinger G, Binder H. Prevalence of Vegetative State/ Apallic Syndrome in Vienna. Eur J Neurol 2004; 11(7):461-6. 3. Higashi K, Sakata Y, Hatano M, et al. Epidemiological studies on patients with a persistent vegetative state. J Neurol Neurosurg Psychiatry 1977:40;876-885. 4. Ashwel S, Eyman RK, Call TL. Life expectancy of children in a persistant vegetative state. Pediatr Neurol 1994; 10:27-33.