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End-of-life care exigencies

We seem to be moving away from ensuring a dignified death in many cases

A 78-year-old male who required assistance from his family members for his routine activities like using the washroom and having food, had a sudden onset of severe headache followed by loss of consciousness. His general well-being was steadily deteriorating for at least a year and he did not wish to have any medical consultation. After losing consciousness, he was not responding to calls from his son, daughter-in-law and grandchildren, and appeared to have breathing difficulty.

This is a situation our society is familiar with. The reactions of caretakers and medical caregivers have significantly changed over the years. It is time we decided on the best approach possible that will benefit our loved ones.

Let’s think of the likely response 50 years back…. Given the age and functional disability of the patient, the sons and close family members would request their family doctor to visit him. The doctor, after making an examination, suggests that he be kept at home. He helps them with placing a feeding tube through the patient’s nose. The doctor also gives them the plan of diet for the patient and so on.

Eventually, he lets them know that the last minutes of life are near and asks them to inform any relatives who may wish to visit him. The family accepts the doctor’s advice and informs close relatives about the sudden deterioration. The patient is quickly surrounded by grandchildren and close relatives who keep talking to the elder, knowing that he will not reply. About five days pass and one

morning the man breathes his last. The wish of the patient not to have medical intervention and the pleasure of listening to his loved ones and being with relatives are fulfilled.

Let’s think of the likely response today…. The son immediately calls the ambulance of a private hospital, which arrives in 20 minutes. The emergency personnel observe that the man’s is breathing pattern is irregular and they fix a tight-fitting mask over the face to deliver oxygen. An intravenous puncture is made and fluids are infused. A prick made on the finger yields a drop of capillary blood and the sugar level is tested. The ambulance then races past the mild-morning traffic and reaches the hospital’s emergency department.

The man is then transferred to the hospital stretcher and taken to the receiving bay. A team of doctors assess him and suspect a brain stroke. The son is called by the treating team and it is explained to him that the patient needs tracheal intubation (a tube placed through the mouth into the wind pipe opening into the lung) and ventilation through an oxygen-pumping machine. The son is also informed of a plan to do a brain scan followed by admission to intensive care.

To the son’s query on whether his father’s condition will improve, the reply is that his present condition is really bad and recovery will depend on what had caused the coma. In the next 30 minutes the cause for coma is found to be a massive intra-cranial bleed. By this time his blood pressure crashes and he is in need of injections to improve blood pressure. The doctors now inform the son that the bleeding is very large and they’ll have to wait for the response to the treatment.

Three days later, there is no improvement in his condition. The son, daughter-in -law and a few close relatives are permitted to visit him in the intensive care ward for 30 minutes daily. They see him from a distance of about three feet and

are discouraged from touching him. They call him from that distance, with no response in return.

Five days later, the doctors tell the son that the man has developed renal dysfunction in addition to brain, lung and low blood pressure issues, and explains the need for dialysis. So dialysis is started, but his brain and lung function show no improvement. Since his blood pressure is too low, the dialysis procedure is discontinued.

On the seventh day of hospitalisation, the man’s body appears swollen and his face is unrecognisable. This condition continues for another three days when the man suffers a cardiac arrest, but the intensive care doctors are quick enough to do cardiac compression and get the heart beating again. The cardiac arrest happens again twice on the next day and finally he is declared dead on the 11th day of hospitalisation.

I am sure none of us will wish to go through such extensive and expensive yet futile treatment at a hospital. Why, then, was the man put through it? Was taking him to hospital wrong? Why did modern doctors and technology fail to save him? Can we predict that technology will fail?

Was taking the man to hospital wrong?

Healthcare’s primary objective is to improve people’s quality of life. Intensive care treatment has the potential to save lives, but not always. Taking the elderly man to hospital was the correct step: if he had suffered a reversible cause of coma (such as low or high sugar, altered electrolyte levels, and so on) he would have survived hospitalisation and been with his loved ones for some more years. Without doing the basic blood test and brain-imaging, doctors may not be able to find the reason for a patient’s illness.

Why did modern doctors and technology fail to save him? Can we predict that technology will fail?

Technology cannot save every person who is ill. Response to initial therapy among critically ill patients depend on many factors, which include reversibility of the condition with treatment, the patient’s age, the extent of organ dysfunction, the level of competency of the doctors, the quality of nursing care and technological support. A common perception among members of the public is that technology supports to heal all types of illnesses. If the same brain bleed had occurred in an individual of a younger age, the outcome could have been survival with limb weakness, sometimes even without any weakness.

But you can predict if the technology will be of benefit to a patient or may harm him. For instance, on Day 3 when the patient showed no improvement, the doctors should have discussed the possibility of a futile effort and a decision taken to avoid further aggressive measures. Intensive care is not without pain. It is associated with intense exposure to pain due to blood sampling and medical procedures. If the outcome is worthwhile, then it is logical to continue the aggressive effort. Otherwise it becomes just treatment-induced pain for the patient with no positive benefit.

On Day 5, when the need for dialysis occurred, the decision could have been different and the man could have been left to leave for home with supportive oxygen. These errors in decision occur both on the part of doctors and patients’ relatives. Doctors may use their knowledge of treatment without any thought for the harm it can cause to the patient. More dangerously, it could be the selfish intention of the doctor to consider the case as just another money-minting opportunity. Healthcare in our country is now officially a business, with foreign direct investment coming in. On the other hand, the patient’s caretaker may be refusing to accept the doctor’s option of discontinuing aggressive treatment measures, and this may make the doctor more defensive and continue the futile treatment efforts.

Dignified death for the elderly and those who are chronically ill, is one that happens at their home (could be the place where they wished to spend the last days), surrounded by their children, grandchildren and great grandchildren, listening to their calls and spoken words. There are instances when relatives seek pardon from the dying person for something they had done to him or her. There are instances when tears are seen to flow from dying persons’ eyes when specific things are spoken about (indicating that a comatose person could still hear and think).

We should all remember that death is the last earthly experience for every human being. Let doctors and relatives make decisions that ensure a dignified death to our loved ones.

truthaboutmedicine@gmail.com

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Printable version | May 26, 2020 11:31:14 AM | https://www.thehindu.com/opinion/open-page/end-of-life-care-exigencies/article26162450.ece

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