Elective ventilation of potential organ donorsBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.6997.121c (Published 08 July 1995) Cite this as: BMJ 1995;311:121
Elective ventilation and diagnosis of death are mutually exclusive
EDITOR,--I am surprised that Hany Riad and Anthony Nicholls wish to debate elective ventilation of potential organ donors further despite recent confirmation of its illegality.1 Adoption of any medical process requires careful scientific investigation and evidence. The published evidence in support of elective ventilation is based on a tiny study in Exeter of nine patients admitted to intensive care.2 Four of these patients were admitted in breach of the agreed protocol, and in one case brain stem death did not ensue in the intensive care unit and the patient was transferred back to the wards after five days. On a national level this degree of error in diagnosis would create enormous distress.
More concerning is the “soft sell” with regard to the extraordinarily difficult areas of timing of ventilation and time of death. In the original study in Exeter six of the eight donors were ventilated before admission to the intensive care unit. Ventilation is now proposed at the time that apnoea occurs in the intensive care unit “so that artificial ventilation can start when natural breathing ceases.”1 Those regularly involved with this stage of patients' care will know that regular respiration in a dying patient seldom transforms rapidly and smoothly to recognisable apnoea. The “last gasp” of an irregular breathing pattern is often confirmed only when bradycardia and asystole occur, and to intervene earlier may relieve hypoxaemia, reduce intracranial pressure, and restore respiratory function. As a result a patient may face the persistent vegetative state instead of death. It is arrogant of Riad and Nicholls to be certain that the onset of apnoea is the time of death. Death can be defined only by properly supervised brain stem testing or by the traditional clinical definition of absence of cardiovascular, respiratory, and neurological function. Until these conditions are satisfied a patient is technically, legally, and morally alive, and the Exeter team's attempt to redefine this is unacceptable. In addition, any possibility of producing the persistent vegetative state is unequivocally unethical.
Persistence in advocating the adoption of elective ventilation despite considerable opposition from those working in intensive care risks jeopardising the excellent relations that have been established between the specialties of transplantation and intensive care. In addition, open debate about differences between the timing and diagnosis of death or the possibility of the persistent vegetative state may be counterproductive to the public's confidence in transplantation.
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