A 50-year-old man with motor neurone disease presents to hospital with respiratory distress following two (2) days of fever and malaise. He is alert and anxious, and an arterial blood gas performed on oxygen (8L/min semi-rigid mask) revealed PaO2 45 mmHg, PaCO2 65 mmHg, pH 7.36 and HCO3 36 mmol/L. He has used a motorised wheelchair for three (3) years but continues to work as an accountant. His attentive wife states that they have discussed mechanical ventilation and are keen for him to receive full Intensive Care support.
• How will you approach the issue of mechanical ventilation in this man?
A decision about mechanical ventilation is necessary but is not urgently required. Time should be taken to talk through the potential problems, and ensuring that the patient and wife are aware of the actual implications of ventilation (likely need for and potential complications of intubation & tracheostomy, difficult or impossible wean, prolonged ICU, long term hospital and home ventilation [if available!]). Discussion should include what factors are likely to be reversible (including time frame). Other input may be appropriate and should be sought (parent unit, treating doctors, neurologists, pastoral care). The issues of consent (who and for what must be clarified). After detailed discussion, patient and wife (if appropriate surrogate) should be able to decide.
In discussing mechanical ventilation with a person who is "keen" on it but who will likely end up dependent on it for a long term, the main concepts which govern medical ethics need to be considered:
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