Intended for healthcare professionals


Written protocols do not solve difficulties

BMJ 1995; 311 doi: (Published 08 July 1995) Cite this as: BMJ 1995;311:122
  1. M S Nielsen
  1. President Intensive Care Society, London WC1H 9HR

    EDITOR,--Much is made by the protagonists of interventional ventilation1 of its approval by, among others, the BMA. The association's guidance included the recommendation that, in each unit, a comprehensive protocol should exist from which no deviation should be permitted.2 It is therefore worrying that, in the study in Exeter on which the strategy is based, circumstances “made some deviation from the protocol necessary” in four of the nine patients admitted to intensive care.3 If this was the case in the ideal circumstances of the centre that pioneered the approach, considerable “bending of the rules” might well occur in less well organised hospitals.

    Robert Francis proposes incorporating appropriately worded consent to interventional ventilation in the wording of the organ donor card as a means of overcoming existing legal barriers.1 He argues that, if competent patients can decline lifesaving treatment, why should they not be able to consent to such a non-therapeutic procedure? This approach is flawed since doctors unhappy with the practice could not be compelled to ventilate patients for whom such treatment would be of no benefit.4

    Finally, even if, as Hany Riad and Anthony Nicholls hope, some legal formula can be found to allow them to resume interventional ventilation, it is difficult to see how the system could operate when, with current provision of beds, the rate of refusal for medically appropriate referrals to intensive care currently runs at 18%.5


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