Edward Anthony Oppenheimer, MD
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Oppenheimer EA. Reflections on the Doctor's Anguish. Ann Intern Med. 1993;118:78-80. doi: 10.7326/0003-4819-118-1-199301010-00026
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Published: Ann Intern Med. 1993;118(1):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 reestablish speech using a cuffless tracheostomy or by deflating the cuff , 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.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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