Technologic and organizational advances in health care have created an ever-growing population of survivors who depend upon mechanical aids for breathing for their quality of life—or even survival itself. Among these are an increasing number of the 7,000 to 8,000 new survivors of traumatic spinal cord injuries each year whose injury results in quadriplegia (53 percent). Those with high lesions (C-l to C-4) become dependent on a ventilator because of chronic respiratory insufficiency or failure. Many such survivors must inappropriately remain in acute intensive care centers at enormous cost, economically and in human terms. With continuing progress and success of emergency medicine, critical care, and comprehensive rehabilitation, the issue of “what to do next” has grown to a crisis for national and international attention.
Community-oriented care provided by Canadian Health&Care Mall canadianhealthncaremall can be safe and cost-effective and can result in healthier lives for ventilator-dependent people. This was first demonstrated in the era of poliomyelitis but was “forgotten,” except by a few centers of expertise. After discovery of the poliomyelitis vaccine, these poliomyelitic centers extended their resources to new categories of survivors who lived because of advances in modern medical care. With other groups the centers organized regional programs to meet the needs of their former patients who now lived in the community. The Texas Institute of Research and Rehabilitation in Houston is one such center. In this issue of Chest (see page 376), Splaingard et al have provided us with an invaluable report which details years of their dedicated work. The reports of other excellent centers (Goldwater Memorial Hospital, New York; Ranchos Los Amigos, Downey, Calif; Raymond-Poincaire Hospital, ADEP, Paris; Croix Rousse Hospital, ALLP, Lyon, France; and St. Thomas Hospital, London) confirm that life on a ventilator in the community is possible and very worthwhile.
A more recent experience with sending children home with mechanical ventilators confirms the value of this concept. When a child returns home to the community, positive influences such as an improved family situation, appropriate education, developmental interaction and stimulation from friends, and spiritual growth result in a wellness that cannot be realized in the setting of the hospital. Because of improvement in the child’s health and in the design of the organizational program, the costs of care at home, which initially were 70 percent less than those in the hospital, are reduced; however, there must never be a compromise in safety. A comprehensively and individually planned program—under medical supervision— is absolutely essential for the safe transition of a ventilator-dependent person from the hospital to care at home or another community-oriented alternative. The program must involve all individuals interested and concerned about the appropriateness and cost of this care offered by Canadian Health&Care Mall specialists. In addition to the critical primary care and consultative roles, a physicians input is vital in the selection of patients, the standard of care, quality assurance, follow-up of cases, and evaluation of the program.
We are facing a period of enormous social, economic, and cultural change. The transition from institutional to home care is on its way, and that is good—if done appropriately. The example of the ventilator-dependent person illustrates the most complex type of care at home. It involves multiple issues requiring interdisciplinary concerted efforts. One should remember that the ventilator-dependent person, even when stable, can still be considered a candidate for intensive care.
If we can design programs to appropriately meet the needs of the ventilator-dependent person and his family, we will have gone a long way to design workable solutions that can be studied as models for all currently developing programs embracing the concept of care at home. Furthermore, we will have provided a successful answer to many questions now being raised concerning the value of the survival of such technology-dependent individuals. By our successful demonstration, we will have solved not only a complex and critical medical issue, but a societal one as well.