15 Feb, 12 | by BMJ Group
Guest post by Dominic Wilkinson
(Cross-posted from Practical Ethics)
Mary is 62 years old. She is brought to hospital after she collapsed suddenly at home. Her neighbour found her unconscious, and called the ambulance. When they arrived she was deeply unconscious and at risk of choking on her own secretions. They put a breathing tube in her airway, and transported her urgently to hospital.
When Mary arrives she is found to have suffered a massive stroke. A brain scan shows very severe bleeding inside her brain. In fact the picture on the scan and her clinical state is described by the x-ray specialist as ‘devastating’. She is not clinically brain dead, but there is no hope. The emergency department doctors have contacted the neurosurgical team, but they have decided not to proceed with surgery as her chance of recovery is so poor.
In Mary’s situation, the usual course of events is to contact family members urgently, to explain to them that there is nothing more that can be done, and to remove her breathing tube in the emergency department. She would be likely to die within minutes or hours. She would not be admitted to the intensive care unit – if called, the ICU team would be likely to say that she is not a “candidate” for intensive care. However, new guidance from the National Institute of Clinical Effectiveness, released late last year, and endorsed in a new British Medical Association working paper, has proposed a radical change to this usual course of events.
Instead of the above course of events, Mary would be admitted to intensive care. Extra tubes would be inserted into Mary’s blood vessels, breathingmachines started, and blood pressure medicines provided – until there had been a chance to talk to Mary’s family about the possibility of organ donation. The idea is that this may provide enough time to find out whether Mary would have liked to donate her organs. This may take some hours, or perhaps even a little longer. If Mary’s family take a while to agree to organ donation, she may have become brain dead in the meantime. Alternatively, intensive care can be withdrawn in controlled circumstances, allowing her organs to be retrieved after her heart has stopped beating. It it turns out that the family decline donation, life support will be stopped in intensive care.
This proposal is a version of a practise called “elective ventilation”. This euphemism refers to the idea of “electing” to provide intensive care for a patient who is not thought to be able to benefit from it – in order that they might donate their organs. In the late 80s and early 1990s, this approach was used by doctors in Exeter to increase the number of organs available for donation. At the time, the main focus was on patients becoming ‘brain dead’. The practise largely, if not entirely disappeared in the UK because of advice that it was illegal to provide treatment that was not in patients’ best interests.
But elective ventilation has been resuscitated. The critical shortfall in organs has led NICE and now the BMA to seriously countenance a major change in the approach to provision of intensive care for seriously brain injured, critically ill patients.
Is this the right approach?
Is it ethical to prolong the death of patients until their (and their family’s) wishes about organ donation are known?
Is it legal?
Let us know your thoughts
In the coming months, the Journal of Medical Ethics is going to have a mini-symposium on the rejuvenation of Elective Ventilation. Papers on any aspect of the ethics of Elective Ventilation are welcome. In the meantime comments here are welcome. What are the key objections to Elective Ventilation, and do they stand up?