LAUSR

Editor—I read with great interest the comments by Menon and colleagues in response to my previous editorial in British Journal of Anaestehsia. I find their comments very appropriate and levelheaded and I have no intention to get into any polemic argument, but would like to clarify a few points: First, although involved with the ICU care of children with traumatic brain injury, I will not claim to be an expert in the field as Menon and co-workers clearly are. My sole aim with citing the results of their very interesting multicentre trial was to illustrate the important issues related to outcomes after advanced medical treatments, where outcomes are not necessarily beneficial either to the patient, relatives or the medical system. Thus, my arguments may well be interpreted as overstated when digging into the details of the controversial issue of hemicraniectomy in the setting of severe intracranial hypertension. I completely agree that the authors of the study should have the prerogative of making the concluding remark of their study. The authors also rightly question who should be the judge of a meaningful life (despite involving pain, suffering and limited autonomy) and who will make the decision regarding the costbenefit for society. I tried to acknowledge this in the editorial by stating that this is not the sole decision by a single doctor (such as myself) but must be an issue for representatives of the entire society to discuss, especially involving patient special interest groups who are the ones who are potentially affected by a change in policy from an “always do everything we can” to a more “restrictive” disability-free survival approach. The comment regarding patients with chronic illnesses I will only say that similar discussions as disability-free survival will also be very topical at the very end of a chronic illness. The issue of providing mechanical ventilation to patients with end-stage amyotrophic lateral sclerosis may be such an example. At the end of the day we need to do the right thing in the larger perspective and not just prolong lives at all costs. Thus, I find it refreshing that various experts within the field of advanced medicine have started to promote the issue of disability-free survival as an alternative to the more traditional mindset. Once again I thank Menon and colleagues for providing important input to this debate, and I hope that others, both pro and con disability-free survival, will carry this discussion forward.