Mumbai: On March 31, 67-year-old Ramesh Nathwani died at Tardeo’s Bhatia Hospital following a cardiac arrest. He was in the hospital’s intensive care unit (ICU) as a result of septicemia he had suffered after an amputation. Mr. Nathwani's relatives claim that they had requested doctors to take him off the ventilator after two doctors (not attached to Bhatia) opined that his chances of survival are slim. The hospital authorities, quoting the absence of an all-encompassing euthanasia law in India, refused to pull the plug.
Mr. Nathwani's son, Divyesh, a grocery store employee, told The Hindu that his family had taken an opinion from two doctors. “Both of them told us that my father had slim chances of survival. There was no point in keeping him on a ventilator as his heart function and blood pressure had fallen drastically.” His father was admitted to Bhatia Hospital on March 15 to treat a gangrene infection in one of his legs. The senior Mr. Nathwani's condition worsened due to a stroke, and he was put on a ventilator in the ICU. On March 26, when the family took a second and, later, a third opinion, the hospital bill was touching ₹3.5 lakh.
“We were in no condition to pay any more,” Divyesh told The Hindu on Thursday. “Our family had accepted his fate and we wanted him to pass away in peace at home.” The family also insisted on taking Discharge Against Medical Advice (DAMA), but the doctors refused. “They waited, giving us hope, and meanwhile, the bill kept climbing.” Matters took an ugly turn after the family alleged that Mr. Nathwani’s body was held back by the hospital, pending the bill clearance. Bhatia Hospital denied this allegation.
Why DNR?
Doctors say medical professionals routinely see families confronting a heartbreaking dilemma: putting your loved one through rigorous medication and bearing the mounting expenses, or letting the patient die so that family members are not burdened with medical expenses. DNR laws exist in various countries around the world, but in India, it is not yet a matter of public debate.
“We frequently get requests from relatives asking us to stop the treatment or asking us to remove the patient from ventilator. What does a doctor or a hospital do in such a situation,” asks Dr. Lalit Kapoor, medico-legal expert at the Association of Medical Consultants, and also a general surgeon. “There is no law that permits us to do so. As a result, relatives feel the doctor and the hospital have a vested interest in increasing the bill amount. It is high time that the government thought about drafting such a law. Other countries are already implementing it. We could take a cue and modify the law to suit our country.”
He added that the decision to euthanise a patient is not an easy one. “It must involve thorough documentation, opinions of several experts, and a valid conclusion that the patient cannot be saved by any means.”
Passive euthanasia
Though passive euthanasia is not legal, some doctors say it is practised on humanitarian grounds without making it public. Patients who have little or no chance of survival are weaned off medication on the insistence of relatives. In some cases, relatives take the DAMA route, and doctors do give in. Take the case of KEM Hospital nurse Aruna Shanbaug, who was in a vegetative state for several decades. In her case, the court had said passive euthanasia can be allowed for a person in a persistent vegetative state.
“But this is not a blanket rule,” explained Dr. Suganthi Iyer, medico-legal expert, who practises in a Mumbai hospital. “If there is such a case, it will have to go to court and the Bench will decide if passive euthanasia can be opted for.”
According to Dr. Iyer, there are two types of deaths defined under law: cardiorespiratory death and brain-stem death. “Brain stem death was recognised in 1994 in order to promote cadaver organ donations. But people are yet to accept it. Even today, live organ transplants (donations by living people; for example, a kidney) are high in number despite having so many brain-stem death patients in hospitals. Therefore, a DNR law is seems like a far-fetched dream.” Dr. Iyer added, several ethical issues arise with DNR. “An important issue to consider is whether relatives have a vested interest.”
Current practice
However, some hospitals and doctors knowingly or unknowingly do get the relatives to sign a DNR form, an illegal practice. One such case is pending with the Maharashtra Medical Council (MMC). A Mumbai doctor, on humanitarian grounds, stopped the treatment of an elderly man at his daughter's insistence. He got her to sign a DNR form, but when the man’s son flew to India, he filed a complaint with the MMC on two points: he was not consulted when his father’s treatment was stopped, and that a DNR form has no legal standing.
In Mr. Nathwani’s case as well, relatives allege that the hospital got them to sign a DNR form on March 31, the same day he was declared dead. But the hospital has called this allegation as false.
