Ethics of HMV and NIV

Ethical dilemmas are common in any chronic condition that is eventually fatal. Ethical principles are determined by society and have been subject to enormous change in the Western World for the past 20–30 years. The Human Rights Act is one example of European aspirations for equality and respect for the individual, which has major implications for medicine. Issues specific to HMV/NIV include access to treatment, respect for patient autonomy, competency, and how it is determined, as well as resuscitation following cardio-respiratory arrest. It is important that we distinguish between the health status of a patient, that may be poor, and his/her quality of life which may be good. The legal and moral rights of parents, children and carers also need to be considered. This can be a particular problem when their wishes are different from the healthcare provider. Some of the most difficult problems arise with acute respiratory failure when there is limited time for consultation or discussion. NIV may have great advantages when the only alternative is intubation. Large variation in practice in withholding or withdrawing of treatments, including ventilatory support, is apparent both between countries and within countries in the Western World. We must also be aware of the ethical issues posed by the limited access to even the most basic healthcare in many parts of the world in comparison to our own luxurious position.