LETTER
Reflections on the Doctor's Anguish
Edward Anthony Oppenheimer, MD
1 January 1993 | Volume 118 Issue 1 | Pages 78-80
TO THE EDITOR:
It is a physician's first obligation to ensure that the diagnosis, prognosis, and options are properly evaluated before making a recommendation to the patient and before responding to a patient's request. If the diagnosis of impending respiratory failure had been made promptly in November 1990, when the patient had progressive dyspnea, perhaps he could have explored his options before emergency hospitalization and intubation. After he stabilized in the hospital, experienced respiratory care could have helped him to re-establish speech using a cuffless tracheostomy or by deflating the cuff [2], possibly adding a Passy-Muir tracheostomy speaking valve (Irvine, California) if needed. Alternatively, mouth-positive or nasal-mask positive ventilation are noninvasive options that are particularly important to consider for someone without swallowing or aspiration problems. Peer counseling should not be overlooked. The opportunity to discuss the pros and cons with someone with a similar condition who is using a ventilator at home should be encouraged. The International Ventilator Users Network and the International Polio Network can be of assistance. The case as presented suggests that this 67-year-old man might easily have progressed to many hours a day of "free time" off the ventilator, with ability to speak while on and off the ventilator.
The literature on withdrawal of ventilator life support is large, and citing some references would be useful to the reader [3-5].
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Author and Article Information
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Southern California Permanente Medical Group; Los Angeles, CA 90027
1. Miles JE, Susan WT. Disconnecting a ventilator at the request of a patient who knows he will then die: the doctor's anguish. Ann Intern Med. 1992; 117:254-6.
2. Bach JR, Alba AS. Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest. 1990; 679-83.
3. Herr SS, Bostrom BA, Barton RS. No place to go: refusal of life-sustaining treatment by competent persons with physical disabilities. Issues in Law & Medicine. 1992;8:3-36.
4. American Thoracic Society Bioethics Task Force. Withholding and withdrawing life-sustaining therapy. Am Rev Respir Dis. 1991; 144: 726-31.
5. Wilson WC, Smedira NG, Fink C, McDowell JA, Luce JM. Ordering and administration of sedatives and analgesics during the withholding and withdrawal of life support from critically ill patients. JAMA. 1992; 267:949-53.
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