Reply to Law and Walkey: Long-Term Outcomes after Prolonged Mechanical Ventilation: What of Those Cast Away?

From the Authors:

We thank Dr. Law and Dr. Walkey for their thoughtful comments about our study (1). The main reason why patients were excluded from the clinical trial is that we could not obtain informed consent (patient refusal or unavailability of an authorized surrogate); only 17% of screened patients were excluded because of medical reasons (hemodynamic instability, profound neurological deficits, bilateral phrenic nerve injury, or life expectancy of less than 3 mo). Accordingly, it is not likely that the excluded patients were sicker than the patients included in the study. Further evidence that selection bias did not influence our results is the fact that our ventilator-detachment rate (53.7%) is virtually identical to the ventilator-detachment rate (54.1%) reported in a multicenter, observational study conducted in 23 long-term acute care hospitals and involving 1,418 patients receiving prolonged ventilation (90% of 1,587 transferred patients were enrolled) (2).

Drs. Law and Walkey cite Michel de Montaigne for a quotation attributed to Diogenes the Cynic. The quotation is taken from Montaigne’s essay “Of Prognostications.” Some translators of Montaigne’s essay attribute the quote to Diogenes the Cynic (of Sinope), whereas other translators attribute the quote to Diagoras the Atheist (of Melos) (3). All Montaigne translators note that the quote is taken from Cicero’s “De Natura Deorum” (“On the Nature of the Gods”), Book III (4). Reading Cicero in the original Latin¹, we see that §89 refers to Diagoras, not Diogenes.

Leaving aside the error concerning the provenance of the quotation, Dr. Law and Dr. Walkey are correct in noting that the opinions of nonsurvivors are never included in accounts of a shipwreck. A small number of historians draw attention to the lack of first-hand evidence from the victims of cataclysmic events. Instead, the voices of victims are commonly filtered through comments of their oppressors (5).

Writing of his own experience, Primo Levi adjured that “we, the survivors, are not the true witnesses . . . we are those who by their prevarications or abilities or good luck did not touch bottom” (6). Levi admits that survivors speak only by proxy, attempting to bear witness for their now mute coevals. Survivors of prolonged ventilation are likewise the only available witnesses of a struggle endured. Their inability to capture the thoughts of nonsurvivors is not a reason to discount their own testimony.

We thank Dr. Law and Dr. Walkey for drawing attention to the striking finding in our study—that 85% of survivors were willing to undergo a further episode of prolonged ventilation—and providing us an opportunity to elaborate on the significance and limitations of survivor testimony.