Health care providers, particularly nurses experience difficulties in caring for patients in hospital and the ones that reside in extended care facilities deemed to be in a “vegetative state”. This condition is described when a patient shows no behavioral evidence of awareness of self or environment. There is brain damage, usually of known cause, consistent with the diagnosis. There are no reversible causes present and at least six months to twelve months have past since the onset (Wade DT, Johnston C., 1999). The clinical diagnosis is not easy due to a broad spectrum from the vegetative state to full awareness and the border between these two states is referred to as the low awareness state. There is no absolute definition exists for low awareness state (International working party report on vegetative state 1996). In general, the patient behaves in a way that implies at times that they may be able to extract meaning from a stimulus and may even be able to respond in goal directed way.

Usually the state is intermittent, with only vegetative responses. Rarely it may be possible to establish some form of rudimentary communication. It is not known if patients have any recollection or appreciation of their situation or whether they can experience physical or emotional pain or even pleasure.

Diagnosis of a permanent vegetative state can not be absolutely certain. Nurses with their best intentions find a great deal of moral and ethical dilemma when faced in providing further life sustaining care. Moreover, they are baffled with the complexity of factors that affect the decision making process in advocating quality of life of the patient as well as providing reassurance and support to their families.

Patients in a vegetative state are unable to give consent, both literally and legally. Therefore, they can be treated only if it is in their best interests (Fenwick AJ., 1999). One may ask that if a patient life should be prolonged by the continuance of medical treatment or care.

Two factors may prevent the option of discontinuing treatment being considered, firstly the responsible health staff may not accept that it is ethically allowable. Issues like personal beliefs may preclude others from making their own choice. Secondly the organization may not allow the process to start, perhaps believing it will be too expensive or will reflect badly on it. Likewise, choice is being curtailed without discussion or consideration. There may be illegal and possibly an ethical to continue life sustenance once the patient is known or suspected to be in a permanent vegetative state (Andrew K., 1997).

Society has responded to these various issues concerning patients in the vegetative state. Focusing mostly on patients who are undoubtedly unaware and on the specific interests of the patient, finding legal maneuvers to allow generally acceptable decisions to be reached. Many ethical questions remain unresolved and problems will often arise. People may broaden the scope to include other parties and to use a fully ethical accounting procedure. The main bone of contention is likely to centre on justice - is it equitable to allocate so many scarce resources to one person who is unaware for most of the time? This will not be an easy question to answer. Although healthy people may rate the quality of life of someone in the low awareness state as very low, the quality people who have a specific chronic illness is determined by social factors and not the disease or impairment, and they usually rate their quality of life as reasonable (Dijkers M., 1997). Patients in the low awareness state seem to want to go on living (Homer-Ward MD, Bell G. Dodd S, Wood S, 2000). Consequently, we can not appeal to externally imposed judgments on quality of life. We may simply have to face either rationing that culminates in the premature and avoidance death of a few people or allocating increasing resources to people who are gaining minimal benefit as judged by most other people (Shiel A, Wilson BA., 1998).