With terminally-ill patients, it is a hard decision between holding fast and letting go… Both the attending doctor and relatives need to make hard choices…

Hold fast, let go

Do not go gently into that good night,

Rage, rage, rage against the dying of the light

Dylan Thomas

As the former Chief Minister of West Bengal Jyothi Basu succumbed to pneumonia, it was the end of an epic battle by physicians attending on him to keep his life going with medical support systems. Death remains an inevitable eventuality but then it has a formidable rival in modern medical science. While the timing of the final exit can never be predicted in the normal course, physicians have a few aces up their sleeves to prolong life with their interventions. This article looks into the minds of stakeholders of a terminally-ill per son hooked to life support systems, keeping the person alive but not kicking.

Difficult decisions

A casual headcount of the demographics of our country would reveal a steadfast rise in the number of people well into their eighties and nineties thanks to better quality of living and medical infrastructure. Also there are numerous life support systems available in the form of ventilators, dialyzing machines, aortic balloon pumps etc. Care-givers have often been called to exercise difficult choices of stopping life-supporting machinery on which their dear and near ones are maintained, as they hold on to the last few signs of life following brain death.

The dilemma of a doctor attending on a terminally-ill patient is an ethical one as it prevents him/her from switching off life support systems in the absence of clear, legal settings. Almost none in our country exercises the option of “Do Not Resuscitate” (DNR), in the event of a near-catastrophic medical event requiring resuscitation and artificial life support systems. Relatives often would be too emotionally disturbed to take the call on when to stop the medical support in such a situation. And none would like to take another's life in their hands! The cost of such treatment is often exorbitant and wreaks a financial havoc on the family of the ‘near-deceased'.

In our country commercial interests have made deep inroads into medical services and such interests often drive hospitals to prolong a brain-dead person on life support, maximising bed occupancy and utilisation of medical services and allied gadgetry. The relatives often fail to see the writing on the wall and leave it to the hospital, hoping to see a turn-around in the medical status of such a patient. This means more hours on ventilators, helping none but the financial bottom line of the hospital.

Nebulous options

There is no ideal situation in this setting and the choices are more nebulous than stark. It is the responsibility of the attending physician to paint a realistic picture of a patient on life support. It is also important that the relatives take a dispassionate decision based on the chances of recovery outlined by the physician on “pulling the plug”. A rabbi wrote many years ago about life's many situations when we humans must chose between holding fast and letting go. This is more pertinent in a host of medical situations too, the latter when life slips into that lonely road of no comebacks. Readers can always take a leaf out of the book of this brave wife of a cardiac surgeon in Madurai who, upon learning that her husband had lapsed into a brain-dead state following a bad fall, decided to donate all his organs to the needy. (Almost three people benefitted from her noble gesture at the height of her personal grief as they received her husband's heart and kidneys.)

And that would be an occasion when Death would definitely delight to help the living…

The writer is Assistant Professor, Neursourgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram.


To die, to sleep no moreFebruary 13, 2010