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Indian Journal of Critical Care Medicine, Vol. 9, No. 2, April-June, 2005, pp. 81-85 Review Articles End-of-life issues for a modern India - Lessons learnt in the West Puri VinodK St John Health System, Providence Hospital and Medical
Centers, Southfield, MI, USA Code Number: cm05013 Abstract Consideration of end-of-life issues is a relatively new phenomenon in the Indian context. It is difficult to assess the magnitude of the problem except the certainty that these issues will affect more patients and their families in the future. The approaches used in the West to prepare patients and public in general such as living will and durable power of attorney have not always been useful. The religious and social attitudes have an effect on facing end-of-life issues and yet these attitudes are in transition. The lack of education in bioethics and paucity of case law is reviewed. New approaches to the end-of-life issues in the light of experience gained in the West are suggested.Keywords: CPR, DNR, DPA, Ethics, Living will Introduction Most commentators about healthcare especially expensive intensive care in India would justifiably worry more about its availability rather than too much care! Still we must recognize that transformation of the dying process is taking place in India at a pace much faster than imagined just a few years ago. Even if for most of the Indians, the Terri Schiavo case in the USA in early 2005 appeared to be foible of a rich nation, the issues may be closer to home. Mani and Kapadia refer to two cases.[1],[2] The supreme court of India seems to have issued contradictory judgments in the case of Gian Kaur vs State of Punjab State.[1] The court stated that the right to live cannot be interpreted to include the right to die an unnatural death curtailing the natural life span. How did the court arrive at the conclusion that removal from life support in persistent vegetative state was cutting short ′a natural life span?′ In an earlier opinion the justices acknowledged that ′...a person cannot be forced to enjoy the right to life to his detriment, disadvantage or dislike.′The essence of developing census on bioethical issues is to reconcile differing points of view, debate the ethics and logic of legal opinions and to adopt pragmatic but principled solutions. It is obvious that the justices need to reconcile the views they have expressed about article 21 of the Indian constitution. The differences between withdrawal of life support as distinct from suicide or murder appear to escape the sensibilities of some jurors. It is not surprising that most of the articles Mani cites are US references for legal opinions. His excellent review discusses the ethical principles such as autonomy, beneficence, and nonmalfeasance and double effect. Many of these concepts have evolved from the Judeo-Christian ethos and from the work of European philosophers over many centuries.[3],[4] An equally vigorous effort to address bioethical issues raised by rapid advances in medicine has been joined by ethicists, physicians, and law people. [5],[6],[7],[8],[9] The medical students receive education in ethics. The residents and practicing physicians continue to receive instruction during their training and years of practice. The principles of informed consent and autonomy are inter-related and are likely to be considered universal human values in the modern world. Therefore, the application of these ethical principles to Indian medical practices is inevitable in the future. And yet it is appropriate to enquire about the experience gained in the West. The use of ′do not resuscitate′(DNR) orders by mid-1970s, to avoid cardiopulmonary resuscitation (CPR) has followed universal adoption of CPR in the American hospitals in early 1960s. Thus in America, we have had over 30 years of experience in utilizing DNR orders.[10],[11] A great deal of published data to assess its impact in avoiding CPR in hospitalized patients exists. There certainly are some important lessons that have been learnt in dealing with the dying patients. It is worth considering whether we can apply some of these lessons to the Indian patients as critical care becomes more commonplace. Suggestions for new or modified hospital policies are provided in the light of the experience. DNR orders Brain-death law CPR in all dying patients? Since implied consent in hospitalized patients is considered to be the reason for universal CPR, an innovative change in hospital policy is required. In that regard, a proposal is made that presumed consent for CPR should be limited to patients who are not likely to suffer a cardiopulmonary arrest in the hospital. In all seriously ill patients, physicians should be required to determine within 24 h of hospital admission, if the patient is likely to suffer a cardiopulmonary arrest and his/her chances of survival after a CPR. This information should be recorded and conveyed to the family members. Of course, this would trigger a dialogue regarding advisability of CPR in case of a cardiac arrest. This change in policy will restore therapeutic rationale to CPR. To protect against low frequency events, it will still cover patients with unexpected deterioration. Advanced directives Demands for marginally effective treatments As safeguards, all aspects of care in DNR patients should be routinely reviewed for indications, mortality, and morbidity. Examples of these include tracheostomy, feeding tubes, dialysis catheters, prolonged antibiotics usage, debridement of bedsores, and parenteral nutrition. DNR decisions whenever rescinded should be reviewed for appropriateness. Peer review process should cover unnecessary CPRs and practices monitored. The purpose of these policies would be to scrutinize practices that result in excessive use of hospital resources and ordinarily will remain un-examined if patients just before death are designated DNR. It is stipulated that patients in persistent vegetative state should automatically be presumed to have DNR designation and excluded from intensive care. The rationale for this important policy is detailed in the accompanying article.[12]
Law and end-of-life decisions Current practices and future directions Consider the current situation in India. It is remarkable that for the moment the Indians are perfectly willing to depend upon cultural attitudes and economic forces to resolve weighty moral issues! A strong sense of fatalism prevails on the subcontinent. It is not just limited to the Hindus, the dominant faith of the populace. ′Whatever God has willed′ is also the professed attitude of many other faiths. Thus acceptance of fate rather struggle for an end is the prevalent attitude. However, it is not likely to remain so. With education will come sophistication and more demanding clientele, who are likely to ask the question ′Isn′t there anything else that can be done?′In fact Kapadia et al. offer that in Mumbai, a cosmopolitan, relatively prosperous city, a lot of terminal care in private hospitals is offered to accommodate the relatives of the patient or avoid conflicts with the family.[2] It may be anecdotal experience but one often hears of ′illegality′of discontinuing mechanical ventilation in dying patients in India![16] In other cases the stories of abrupt withdrawal of life-support systems when families are unable to pay for medical care also abound. Shouldn′t we be equally concerned about the immorality of these decisions? One can at least hope for a universal code of medical ethics. A peculiar designation in India is ′left against medical advice′(LAMA). The practice to take a dying patient home seems to absolve the medical community of responsibility to deal with questions of treatment withdrawal. Most of such decisions are based on acceptance of fate or a lack of money to provide continued care. Mani points out that this represents unilateral withdrawal of care by the family based on lack of financial resources.[1] Even though that statement is true for the most part, complicity of the physicians in this decision is not uncommon. When intensive care becomes universal across India, would the doctors be able to say as they do now that the end is inevitable, survival unprecedented and ′it is time to take the patient home.′That the patients relatives actually take a dying patient home may come as a surprise to the physicians in the West. Partly, there is a lack of facilities such as hospice and long-term care facilities in India. In developed countries, many of the elderly or disabled patients waiting to die reside in facilities that provide subacute care. The latter is also likely to change in the future. Third-party insurance or affluence of the population will make continuation of life support and other expensive treatments easier to accept. Thus there is a need to examine the ethical basis of decisions at the end-of-life.[16] It is worth noting that the paternalistic European practices which are closer to Indian practices are undergoing a change as well, endorsing a shared decision making process.[17] However, what is needed is a clear-eyed recognition of the responsibilities of the medical profession, which do not diminish just because the family members can no longer afford expensive care. It is suggested that physicians perhaps would have been wiser not to initiate treatment or withdraw it earlier if the prognosis was dismal. Conclusions The end-of-life issues are likely to affect many patients and families in ways not experienced in the past.[14] If we wish to avoid some of the ineffective medical practices in the use of life-support technologies, we need to be aware of the pain and suffering caused by new technologies. The medical profession has a responsibility to use newly available devices and technology wisely, compassionately, and honestly, recognizing its limitations. Guiding the patients and their families both regarding initiation and withdrawal of treatments with aim of diminishing pain and suffering must remain paramount. The fiduciary responsibility of the physicians will not diminish even if universal health insurance becomes the norm.References
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