Last machine standing

We must draw up living wills on what should be done when there is an end-of-life event.

Written by Easwer Hv | Updated: March 19, 2015 6:11 am
medical bodies in India have evolved guidelines. Physicians can use them when confronted with issues pertaining to end-of-life care. medical bodies in India have evolved guidelines. Physicians can use them when confronted with issues pertaining to end-of-life care.

If you ask a philosopher what the most precious thing about life is, the answer would be, life itself. Almost all human endeavour is to preserve life and prolong it as best possible. It is here that a humble human invention called the ventilator comes in — to preserve life and, most often, prolong it in that ultimate battle with nature. Ventilators function as breathing bags, pumping in much-needed air for a patient. It often helps drive in oxygen and remove carbon dioxide when the lungs and other organs fail, or when the brain fails to protect the lung.

If you ask a philosopher what the most precious thing about life is, the answer would be, life itself. Almost all human endeavour is to preserve life and prolong it as best possible. It is here that a humble human invention called the ventilator comes in — to preserve life and, most often, prolong it in that ultimate battle with nature. Ventilators function as breathing bags, pumping in much-needed air for a patient. It often helps drive in oxygen and remove carbon dioxide when the lungs and other organs fail, or when the brain fails to protect the lung.

There was a time when public hospitals, the only sources of healthcare in our country, were woefully under-equipped with ventilators. The plight of a patient waiting for one to be free was seen even in the revered medical institutes. In the prestigious Postgraduate Institute of Medical Education and Research, Chandigarh, the sight of relatives using manual “bag” ventilation was all too common in the 1990s. Often, this manual ventilation by hand-held bags was at the mercy of the operator, who might go off to sleep or get tired, leaving the patient literally breathless.

The last two decades have seen the advent of corporate hospitals and they sensed a huge opportunity in intensive care and ventilators. The machines became commonly available, at least in the bigger towns and cities. The ventilator has become the last measure to prolong life for many who have access to such facilities. In many cases, especially in head injuries, the machines have made a difference in outcomes. But that is only half the story.

In India, terminal care and “end-of-life issues” are a grey zone. Many patients who have no chances of reverting to normalcy are hooked to machines, as there are no clear “do not resuscitate” instructions. As life expectancy increases, we are witnessing more people getting stuck to these machines in their last days. The family refuses to exercise the option of switching off the ventilator due to emotional reasons, hoping for a miracle. Many feel that switching off a ventilator is tantamount to taking away a life.

Indians who leave the country for work often have old parents back home. When a parent enters the terminal phase of life, the child pleads with the physician from a faraway place — “keep him/ her going until I reach home” — for emotional reasons.

When do we need to keep our ventilators chugging? That is a question no one can definitively answer. Physicians must give a realistic picture of the clinical status of patients on life support, ensuring that their near and dear ones understand it. All of us, when alive, must exercise the option of a “living will” on what should be done when there is an end-of-life event. Our life’s stakeholders — relatives and friends — must respect this, avoiding unnecessary and prolonged stays in intensive care when the writing on the wall is clear. Professional medical bodies in India, including the Indian Society of Critical Care Medicine, have evolved guidelines in this direction. Physicians can use them when confronted with issues pertaining to end-of-life care instead of resorting to arbitrary decision-making.

Organ donation from dying patients is slowly gaining ground in India, as any patient who is brain dead and on life support becomes a potential benefactor. All of us must consider this as an option when we die.

The writer is a consultant neurosurgeon based in Thiruvananthapuram.

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