Making Sense of Bioethics: What About Ventilators?

 The use of ventilators can pose particularly challenging problems during end-of-life situations for families. When should we place a loved one on a ventilator? If somebody is on a ventilator, can we ever “pull the plug?”  The answer depends on whether the use of a ventilator in a particular case can be considered “ordinary” or “extraordinary.”

Ordinary interventions can be understood as those medicines, operations and treatments that offer a reasonable hope of benefit for the patient and that can be obtained and used without excessive pain, expense, or other significant burden. Use of a ventilator will sometimes satisfy  these criteria, and at other times will not depending on the details of a patient's situation.

Consider a young woman with serious pneumonia who is having difficulty breathing and is placed on a ventilator. The physicians treating her believe the pneumonia eventually can be controlled so that she can be weaned off the ventilator and breathe on her own in a few days or a week.  They believe the device will be needed mostly as a temporary “bridge to healing,” that it will be effective while in use, and that it will not impose much burden on her. In such circumstances, the use of the ventilator could reasonably be considered “ordinary” and thus morally obligatory.

Whenever there is a considerable hope of recovery from the illness by making use of a particular means (a ventilator, in this case), and when the patient can employ the means without much difficulty or burden, it is likely to be “ordinary” treatment. Thus, in the experienced hands of a well-trained physician, in a developed country with access to proper medication and equipment, intubation and ventilation of a patient can be a low-burden intervention.

 The difficulties  associated with using a ventilator, however, can become notable depending on the details of a patient's situation. Dr. Stephen Hannan, a pulmonary and critical care specialist in Fort Myers, Fla,recently summarized some of the burdens associated with ventilation, noting particularly: 

“…the physical  discomfort of  the  endotracheal  tube going from the mouth,  the oropharynx, crossing  the larynx, and reaching the trachea. Sedation, analgesics and physical restraints  are often  necessary. The patient cannot talk while ventilator support is in use. The ventilator exposes the patient to greater risks of infection and barotrauma [damage to the lung tissue from the pressure of  ventilation]. Even  an  un- trained observer will recognize that the burden imposed by a ventilator with a standard endotracheal tube is much greater than the burden of a feeding tube.”

 We can consider an example that highlights these burdens: an 85-year-old grandfather is placed on a ventilator after suffering several serious strokes that damaged his brainstem so that he cannot breathe on his own. The physicians treating him are convinced that the damage from his most recent stroke will continue to get worse, with the nearly certain outcome that he will die in a few hours or days. Assuming  that he  is unconscious,  and that other matters have  been taken  care of (last sacraments,  opportunities  for  loved  ones to say goodbye, etc.), the family could reasonably conclude  that  continued ventilation  would be “extraordinary” and decide to have the ventilator disconnected,  even  though  it  would mean their grandfather would  be expected to die in a matter of minutes without it. Such an act of withdrawing the ventilator would not be an act of euthanasia, because he would be dying due to the underlying condition. It would be a recognition of the burdensomeness of continued ventilation and an acknowledgement that heroics are not required, especially when death is imminent.

Occasionally ventilators  may end up being part of a long-term solution for a patient. 

Christopher Reeve, who played Clark Kent in the movie “Superman,” for example, was able to live for several years with a tracheostomy and a ventilator  following an equestrian accident  that severely damaged his spinal cord. The ventilator, while clearly a burden, offered many benefits to his situation as well, and in the final analysis, seemed to be a reasonable and proportionate intervention for his particular set of circumstances.

Other cases with ventilators can be more difficult to decide because a prognosis may be uncertain or debated.  Sometimes  the expense of providing long-term ventilation and critical care may need to be factored into  the  judgment about whether ventilation is ordinary or extraordinary. Determining whether there will be a “reasonable hope of benefit” to a particular patient by using a ventilator can be challenging. Each  case must be considered on its own merits, as we seek to  make a good prudential  judgment, and to provide for our loved ones in a way that corresponds to their real medical needs, so that we neither neglect nor overburden  them  in  the  face  of  powerful medical technology.

Father Tadeusz Pacholczyk, Ph.D., earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, Mass., and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. Father Tad writes a monthly column on timely life issues. From stem cell research to organ donation, abortion to euthanasia, he offers a clear and compelling analysis of modern bioethical questions, addressing issues we may confront at one time or another in our daily living. His column, entitled “Making Sense of Bioethics” is nationally syndicated in the U.S. to numerous diocesan newspapers, and has been reprinted by newspapers in England, Canada, Poland and Australia.

For more from Father Tad and the staff of the National Catholic Bioethics Center, visit www.ncbcenter.org.