Elective ventilation is cost effective and humaneBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7016.1370a (Published 18 November 1995) Cite this as: BMJ 1995;311:1370
- Hany Riad,
- Anthony Nicholls,
- Charles Collins
- Consultant renal transplant surgeon Consultant renal physician Formerly director of intensive care Royal Devon and Exeter Hospital, Exeter EX2 5DW
EDITOR,--We expected that our defence of elective ventilation1 would provoke criticism and wish to respond here to letters on the issue.2 Peter G M Wallace rightly says2 that the published experience of elective ventilation is limited to nine patients. The table summarises our full experience over six years. Two further patients became non-heart-beating donors as the relatives agreed to organ donation (and elective ventilation) but no intensive care unit bed was available. The 23 donors yielded 41 kidneys, two hearts, three sets of heart valves, one liver, and 20 corneas, which were transplanted with favourable outcomes.
Moving a patient back to a general medical ward does not create distress if the family members are supported: they consider that everything possible has been done for their relative.
We are not proposing a “soft sell” on the timing of death. We raise the philosophical issue of when death can be said to have occurred in patients who are subsequently diagnosed as brain stem dead. It is not in any biological sense the moment that tests for brain stem death are done, though this may be the legal definition. The conference of royal colleges and their faculties recognised in 1979 that in certain circumstances death was a process rather than an event, and its statement has not been superseded by any other document on the diagnosis of death.3
The risk of a vegetative state is the same with conventional therapeutic ventilation as with elective ventilation. Over half of donated kindeys in Britain come from patients with intracranial haemorrhage who are therapeutically ventilated. There are no published data to show that a vegetative state is common in this situation. There is no reason to fear that it would be a major risk with elective ventilation.
Alex Manara and Claire Jewkes argue that the interests of an individual always have priority over the interests of society,2 but natural justice places the greatest good to the greatest number above individual self interest. We do no overt harm to anyone by using elective ventilation, and the good is clear for all to see.
Elective ventilation does not result in a loss of dignity during death. Patients with fatal brain haemorrhage are often managed by junior medical staff alone, with little involvement of consultants and poor support for relatives. In contrast, senior staff are involved in elective ventilation at all stages, and relatives are given extensive counselling by experienced staff. The families of our donors have complimented us on the level of support given--this is hardly evidence of loss of dignity.
We are open about variations from our original protocol, pointed out by M S Neilsen.2 Our refined protocol differed considerably from the initial one in that ventilation was started only when apnoea developed. It is sensible to modify practice in the light of experience.
The issue of resources is one of the strengths of elective ventilation, rather than a weakness. Precious NHS resources ae being diverted into expensive dialysis programmes for an increasing population of patients with chronic renal failure. Far from consuming precious resources, elective ventilation unlocks money from dialysis budgets, because transplantation is cheaper. The transfer of saved money from renal to intensive care budgets is a management exercise, not an ethical issue.
The true hidden cost of banning elective ventilation has to be balanced against the theoretical objections that have been levelled against us. We believe that the ball is firmly in the court of our legislators and the medical royal colleges, who must act to legitimise a humane, practicable, and cost effective procedure.