End of Life Directives – The Debate Continues

I know, I know. In this week of holy cows coming down to earth and aging actresses shaking their chubby navels, it seems boring to get back to dying-related problems. I try not to do follow-ups, but last week’s article raised quite some hackles. Many on the other side of 60 and 70 wrote in and were quite adamant that their wishes regarding end-of-life (EOL) directives should be followed, come what may.

Clearly, prolonging a life without dignity is not right…in principle. But I wrote the article last week because of the angst felt by a couple of friends in the recent past, when they had to decide how to handle their dying parents and their wishes. It is all very well for people to leave such “living wills” and do-not-resuscitate (DNR) letters. But if you look at it from the perspective of the relatives who have to take decisions based on these directives, the mental and emotional trauma they have to go through, especially if they are not reconciled to letting their near and dear ones go, can be tremendous. In that context, if the son or daughter decides to try one last time, how can that be considered “wrong”? How can people load guilt on an already stressed individual who in any case is trying to balance multiple counter-points and one-anna advices from “well-meaning” relatives?

I repeat. When it comes to following EOL and DNR wishes, if the relative is unable to do so, then he/she should not be castigated for taking that judgment call.

I also received emails blaming doctors for keeping patients alive in the ICUs for many days, with the sole intent of making money. And while that may be true in some instances, it is unfair to the medical profession to make such sweeping statements.

Two arguments!

To be crude and blunt, the most money to be made out of a seriously ill patient in the ICU is in the first few days when a large number of tests and procedures are to be done. Beyond four-five days, the patient actually becomes an opportunity cost, paying only bed and some routine laboratory and medicine charges, when another more seriously ill patient could have generated more revenue in his/her place. And so the argument that a doctor keeps a patient in the ICU artificially alive for many days just to make money, especially when even average ICUs in this city have no beds at most times, doesn’t make sense, purely from a business perspective.

More importantly, doctors are trained to “save” patients. Their entire training is geared towards keeping patients alive, not letting them die. In that context, if the doctor wants to keep trying, even when there is just that little hope left, it is insane to blame him for doing so and to assume that all these efforts are just to make a little more money. And honestly, if you truly believe that there is no further hope for the “dying” relative, you should have the guts to tell the doctor to stop trying and ask to take the patient away…to have the courage to take a decision that may eventually lead to that relative’s demise. It’s a tough call to make…not just for you, but for the doctor as well!

It is a complicated issue. 1200 words can’t do justice to it. But to blame doctors or relatives for not adhering to EOL directives, for trying everything possible to revive a patient, holding onto the most slender hope…and assuming there are ulterior motives…is unfair!

12 Comments

  • suraiya merchant wrote:

    i do think that if a person has given dirctives pertaining to EOL or DNR, the relatives concerned should adhere to the persons wishes – a person is entitled to the right of living with dignity – and he /she has to live their own life – no one can live for you and share your physical sufferings – – not the relatives and not even your nearest and dearest – hence the person should just respect such decsions if they are entrusted to do so – and surely a doctor cannot push you beyond a point to insist on taking treatment – i also strongly feel that our laws should allow for the provision of makin a Living Will- further , if the person concerned has explicitly stated to abide by DNR directives , they should do so because if the person continues to live an undignified or lifeless existence , this should make the relatives more guilty than going by their decisions which may be contrary to the relatives point of view and which the patient is then inflicted with

  • H.L. Chulani wrote:

    Everyone loves to play the victim- blaming the doctor is easy since he is last thread between the patient and relatives/friends! A true incident- A Bollywood Producer of a film depicting doctors in real and reel life had his mother admitted in the ICU. After a few days on the ventilator, though the mother was conscious and aware of her surroundings this ‘son’ wanted the doctors to pull the plug of the ventilator since he could not ‘bear’ to see his mother suffer! When refused he asked the doctor if he had seen the movie he had produced! On the answer being affirmative he called the doctor an ass-hole and threatened to call the police- an empty threat to impress other relatives! I call him the fourth idiot!

  • While we have to understand that no a blade of grass moves God’s consent, we have to honor the heartfelt wishes of a person’s EOD.
    Don’t we follow his will to bequeath his/her assets Verbatim.
    Then why not his/her Living will.
    Regards doctors being money minded, there are always a few rotten apples in every field.

  • V.Subramanian wrote:

    The clarification that it does not make business sense for doctors to keep the patients for more than the initial 4 or 5 days in the ICU seems credible. But then the observation that most ICU do not have beds,at most times,may not be entirly correct.As a doctor you have expectedly put up a spirited defence of your fraternity. Your willingness to debate on these issues,while setting you apart, may also be a tacit admission of a prevalent problem of greed especially in a corporatised era, where maximisation of profits and quarterly growth figures are important for hospitals.I do not seek to generalise this malice. Whenever we see from a business perspective the overwhelming conclusion is that Ethics go for a toss especially in the field of medical treatment.We have also heard that several doctors have honestly explained to the relatives, the futility of further treatment.The Age and economic state of the relatives play a part as well.Most hospital authorities do not pull out the ventilator plug,inside their Hospital premises. Hope we move on to more cherrful topics, next week.

  • Bhavin – there may be detractors but you I am with you on this one. The near ones are in a dilemma. Its a fine line they have to draw between not putting them through suffering vs trying when there could be a possibility. Its a call the near ones in their heightened emotional state have to take. As you say its neither right nor wrong.

    Have been there a few times. Nani – meningities, tried until doctors stated that if she came out she would be a vegetable. Let go.

    Kaka – Series of heart attacks at home. Took him to HN, in the hope of helping but lost him in few hours.

    Mother/Kaki – Terminal cases. All treatment at home.

    Wife – Very very aggressive intervention for acute MG (bulbar form) at HN (Plasmaphersis – 6 rounds, IV IgG, Thymectomy). 45 days on venti. Several ups and downs. 4 1/2 months before she could eat and speak. Is now living a normal life.

  • Sundaram M R wrote:

    It is a battle of emotion and duty to implement the desire of the dying. Every one has a right to live as well as a right to die than to be forced upon to continue ‘clinical life’. All said and done, volumes written and decibals spent it still remains a tough call one has to make personally, be it the doctor or the care taking near ones! A perennial diellemma :(

  • If illness is acute and curable with even the slightest chance, I agree with your comments.. But prolonged terminal illness trust me at some point u will start questioning the purpose of your efforts. Is it ok keeping them alive so that you feel u did everything even when illness is terminal, awareness of mind is minimal and suffering is present.? Makes u feel sick either ways. Thats where end of life directives are a boon.

  • Mrs. Mehroo S. Kharegat wrote:

    At my age I reflect with horror the prospect of living like a vegetable. Offhand I tell my family to let me go in peace if this were, God forbid, ever to happen.
    For the first time, reading your article it suddenly occurs to me how difficult it would be for a loved one to implement my wishes. I have no answer.
    However blaming the Doctor is ridiculous. Perhaps there are a few who prolong for monetary gains but as you so rightly put it, there is more to gain from various tests than letting a patient lie in this state. As a very prominent Physician in Bombay once said to me when discussing a patient whose relative suggested Euthanasia and he declined was “Mehroo, I am not God”.r

  • Jayesh Desai wrote:

    you have raised a tough subject which people generally want to avoid but it helps if there has been prior discussion thereby creating awareness. I wonder how many people create will in advance when they are well. That is another subject but after six month, bring on something cheerful like subway in king circle or vintage Shridevi in engvng.

  • Rohit Gosalia wrote:

    I have known a friend – ho had to take the decision – when his father was at Asian Heart Institute after Heart Attack. Doctors tried – but eventually – a stage came when Doctors clearly told – chance are 50-50. Also in all probability – even if his father survives – he may go in vegetative state. My friend spoke to his father – and with heavy heart he told him – your time is up. Father agreed and eventually – father passed away peacefully. I respect his Guts.

  • Bernadine Pramodhan wrote:

    Everyone is entitled to his/her opinion.The right and decision to either Live or Die with Dignity should be mine alone.I died a million deaths when I had my Mum ask me, (everytime I had to clean her after she had defecated)to give her something so she could be at peace.Her eyes said it all, although she knew I loved her and wasn’t doing it out of a sense of duty.There was no Dignity left for that Woman of Substance that I looked upto all my life.Why cant my last wishes keep me happy? rather than those around?

  • I think some of you have confused DNR with Euthanasia. Euthanasia is about killing yourself to end suffering and pain. Legal in some countries, illegal in India.

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