Easeful death

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#31 May 15th, 2018, 17:31
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#31
Your Harvard friend was right. There are public service announcements now in the US recommending people use holiday gatherings like Christmas to bring up end-of-life issues, though most folks are reluctant to discuss death, in most families a big taboo. It really helps to have frank discussions with loved ones BEFORE the moment of truth arrives, even if this is awkward. Of course, getting the hospital to honor those wishes is a totally different matter, even when the proper documents have been prepared. Been there. Every hospitalized person needs an advocate present, if possible.
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#32 May 15th, 2018, 20:20
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#32
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Originally Posted by snotty View Post This may go against the tone of the conversation so far, my voice being a part of it.

An incident from the ICU - A lady was bought by her husband with breathing difficulties. Was put on the ventilator. The lady, around 55-57 years old, had some brain pathology which had made her not respond to external stimuli apart from pain for the past 5-6 years. She however did not require any life support intervention. No tubes were inserted when she was out of the hospital, fluid diet was being given. The husband would look after her with immense dedication. He had ensured that she did not get a single bedsore despite she not being able to move by herself. He would spend time with her, even after her 'needs' were met.
She used to be bought to the hospital once in 3-4 months with respiratory infection, which on occasions required ventilatory support, may be due to muscle fatigue or weakness or low respiratory drive secondary to the infection. On one such occasion, she required ventilator for a longer period and we were not able to wean her off the ventilator - she would not be able to maintain the oxygen saturation without that support. We spoke to the husband, who insisted that ventilator support be maintained till she would be able to breathe by herself. I am not going to go further with the story.
What I would like to mention here is the presence of a emotion known as love. An emotion that often does not let you look at the difficulties or the impossibilities but at the possibilities. An emotion that is seen not just in humans but in animals around us and in the wild as well. A baby elephant not leaving the side of her dead mother, a zebra taking care of her calf as they take part in the great migration in Africa. The instinct to care is present across species, an instinct to protect and nurture is usually seen unless corrupted by other factors.
A life and death decision cannot be done based on a mathematical algorithm, where the only colours permitted are black or white. There are hundreds of shades of greys involved in real life.
Do not deride love by labelling it as being selfish. Let us be human too.
Note - I do not call for extended sufferings. I call for the dilemma to exist and then to make a decision that would take both the patient as well as the loved ones in consideration.

Sorry narayanvee, if this post sounds contradictory to the flow of the advice so far.
Did the patient surname start with D? I knew someone in similar circumstances in Pune
#33 May 15th, 2018, 21:06
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#33
This was almost 15 years back.. Sorry, unable to recall the name.

And you will be surprised to know that a number of patients are in similar conditions across the country - I know atleast three others in Pune.
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#34 May 15th, 2018, 23:28
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I wanted to correct something I wrote earlier---I said "There is no concept of hospice in India". I did some googling, and that is not exactly true, in the sense that there are charitable agencies (not enough of them) that care for the dying poor. Maybe some of them would not be dying if they could afford health care, but that's a bigger story.

What seems to be absent in India is hospice care for the middle class and the rich---people who could afford good service either at home or in a facility, from staff experienced in end-of-life care and in emotional support for relatives. Many people have more money than judgement, and are at the mercy of predatory doctors and hospitals.

Some months ago in another thread I described a dying relative who ended up in a Mumbai hospital, getting first-class (and totally inappropriate) medical attention. Several specialists would drop by every day, say hello, and bill large amounts for their time. Every time he started to die they would revive him. Of course they force-fed him through the nose also. These predators should be stripped of their medical licenses.
#35 May 16th, 2018, 08:13
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#35
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What seems to be absent in India is hospice care for the middle class and the rich--
Most people who can afford it try to provide some kind of care at home. Have seen a combination (depending on finances) of daily doctor home visits, so called 24-hour medical attendants (normally useless except as warm bodies in the vicinity of the patient) in shifts or qualified nurses (much more expensive but better), oxygen supply et al. I think there is stigma attached to 'abandoning' your near and dear to an outsourced facility still. This is also done for people with chronic but not necessarily immediately life threatening conditions. I did some of these things for both my parents, not for the stigma but because I had no real alternative; in any case, they would have been miserable in a hospice kind of place.

If you can't afford it you just die however.
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#36 May 16th, 2018, 08:22
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#36
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Originally Posted by RPG View Post I wanted to correct something I wrote earlier---I said "There is no concept of hospice in India". I did some googling, and that is not exactly true, in the sense that there are charitable agencies (not enough of them) that care for the dying poor. Maybe some of them would not be dying if they could afford health care, but that's a bigger story.

What seems to be absent in India is hospice care for the middle class and the rich---people who could afford good service either at home or in a facility, from staff experienced in end-of-life care and in emotional support for relatives. Many people have more money than judgement, and are at the mercy of predatory doctors and hospitals.

Some months ago in another thread I described a dying relative who ended up in a Mumbai hospital, getting first-class (and totally inappropriate) medical attention. Several specialists would drop by every day, say hello, and bill large amounts for their time. Every time he started to die they would revive him. Of course they force-fed him through the nose also. These predators should be stripped of their medical licenses.

There have been cases in Kerala, where relatively posh hospitals in Kerala have given treatment even after the patient has died.
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#37 May 16th, 2018, 11:33
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#37
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Originally Posted by JOHNLORD View Post There have been cases in Kerala, where relatively posh hospitals in Kerala have given treatment even after the patient has died.
It's a pan india thing. Patients are kept on ventilator support and meter keeps running.
#38 May 16th, 2018, 11:39
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#38
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Originally Posted by RPG View Post Some months ago in another thread I described a dying relative who ended up in a Mumbai hospital, getting first-class (and totally inappropriate) medical attention. Several specialists would drop by every day, say hello, and bill large amounts for their time. Every time he started to die they would revive him. Of course they force-fed him through the nose also. These predators should be stripped of their medical licenses.
Not going into the details of this case but shouldn't relatives take some of the blame too? They can and should ask the doctor for a realistic assessment and then take a call.
I am writing this while sitting outside an IMCU where my father is admitted since the last 9 days. He isn't critical but due to his advanced age and a weak heart, minor problems keep cropping up. I have taken my decision. Will ask for a discharge as soon as the doctor comes.
#39 May 16th, 2018, 12:31
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#39
I happen to be from the widely panned community out here and the views expressed are personal..

Do remember that often you get to hear what you want to hear. Go to a mechanic and say 'Boss, the vehicle is old, just get it going' - he will give you an estimate with just the immediate repairs required. You say 'I want this vehicle as good as you can make it' - you will get a way bigger estimate. Mind you - it is the same vehicle in the same condition.
Now I am not equating doctors to mechanics. I am just saying this happens across all professions. But then medicine was supposed to be a 'noble' profession - so how can you apply the norm you apply elsewhere here too.
I believe it has been a two way process and both the providers and consumers contributing to the sharp decline in the quality of care and the satisfaction in the profession.
There has been a generation shift in the way things happen across the society. Everyone is in a hurry to get things, do things, enjoy things and criticise them as well. RUSH! We do not see the level of dedication that was there in the older days in factory workers, in engineers, in CAs, in rickshaw drivers, in hotel owners, in tourist guides - people out here who have been old timers can tell you this way better than me. The medical profession too has been no different. But then so are the folks who visit them.
Patients and the relatives often visit doctors for the results, not the process. Often need instant solutions and results - any delay is a certificate of incompetence. Any adverse outcome a reason to abuse and at times assault the health care provider. Doctors tend to be defensive as well - order a battery of tests to cover all bases (and their a**es). I often see patients come in demanding for imaging tests, not realising that depression, addiction, stress, anxiety and marital discords are not going to show up in MRI and CT scans. But they feel that the doctor would miss something if he doesn't see 'inside' their heads. They need validation for their symptoms that are otherwise not accepted in the society.
Relatives often feel comfortable by spending money for their near and dear ones at times, to make up for the lack of quality time that they may have spent with them. 'We gave him the best medical treatment available.' Now for this best medical treatment, you are going to pay more. Why not give him the best medical treatment he needs and not the best available.
Here is where the medical fraternity goes wrong - often they induce fear and guilt in the the mind of the relatives, reinforcing their beliefs and nudge them towards more invasive tests and treatments. (as above - say what the relatives want to hear). The world has become more materialistic and doctors are very much a part of the world. Not a very proud statement, but a reality. I had a patient who wasn't impressed by my set-up and said as much to me. I did ask him if he wanted a decent doctor or a chic clinic. Guess he wanted the later and didn't turn up later. Now if hospitals and clinics have to be as well maintained and decorated as hotels and restaurants - it does cost money. (I still have to redo mine, even after 5 years of that rebuke!).
I understand that the feeling of anger is more because doctors/hospitals are often approached in times of dire needs and the charges are seen as extortion as you are in no position to look for alternatives at that time. So they need to be more considerate. But wouldn't it be too much to expect the doctors/hospitals to isolate themselves and stand out like an island in face of a increasingly materialistic world. But I still expect them to try and do that. Be as humane as they can be and definitely not exploit during this period of need. There are so many issues involved here that it cannot be covered in one post or may be even 10. There are way more rotten apples in the basket now than can be neglected as such. Often it is the pressure of the investment in infrastructure and education that changes the approach to patient care - and it is a very bad reason to justify the same. It is a malaise that needs to be addressed but then there are other factors which would have to be simultaneously taken care of to get that done.
The working hours are pathetic, the pays not so great when seen across the speciality, the education that gets over by the age of 30 - 35 yrs and then the productive years are not as many as well. So a rush again to get as much as you can in this period. Yes, it was not a forced choice, you chose it - rather struggled and fought to enter that profession. So why complain now. Accepted!!

Note - I think I am good with the short posts, the long ones get too philosophical!
Last edited by snotty; May 16th, 2018 at 22:41..
#40 May 17th, 2018, 00:44
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#40
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Originally Posted by RahulDeva View Post Not going into the details of this case but shouldn't relatives take some of the blame too?
Yes, absolutely. But people never prepare in advance for such things, they have no comprehension. As stated by another poster, you have to be ready, you cannot think straight once things are happening.

For many people of some means, modern medicine is ultimately a curse, yet, until that point it is hugely beneficial.

Also it can be very difficult to extract someone from a hospital once the person has entered. In the specific case I mentioned, the person lived alone and nurses had been hired. These nurses took him to the hospital, probably in exchange for a payoff from the hospital.
#41 May 17th, 2018, 14:51
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#41

Easeful death

I have not been able to go through some of the last posts here, as my mother's condition remains fluctuating; she has grown weaker. By the way Hospice is not very popular in India even if it functions here. In Kerala The Palliative Care Society is very popular and mainly aims at alleviation of pain in terminally ill people,and attends to the needs of severely disabled people. Pallium , based in Kerala is an all India organisation founded by Dr. M.R.Rajagopal , who has been awarded the Padmasree recently. But I don't think that they have any arrangements for attending to the needs of elderly people who are not ill but who are waiting to die peacefully.
#42 May 17th, 2018, 16:24
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#42

Easeful death

As already pointed out in some of the previous posts, the hospitals have become an industry in Kerala-I know for sure-and may be everywhere in India and they are there not to serve the people but to make the venture as profitable as possible. Even some of the hospitals run by so called charitable and spiritualistic organizations function the same way. Most of the doctors are just tools and agents of the management who are more than willing to toe the line of the management. They are told to order for costly investigations and tests though many doctors are aware that these are not necessary. This is a shocking situation and the government run hospitals do not have enough facilities or infrastructure to cater to the needs of the large number of patients.Some of the doctors without just batting an eyelid orders a patient to be admitted to the ICU and ventilator support though they know nothing can be done and the patient will be charged 10 to 20 thousand rupees daily. I know cases like these and the relatives who are not able to take a decision are caught in to this trap.One of my friends was telling me yesterday about his experience in an Ernkulm hospital where he knew the doctors and yet was prescribed some unwanted tests and when he asked the doctor whether these were essential he was told that they were and if he felt not necessary they will continue without the tests. The disturbing question is what is the way out and who will control these mafia groups.
#43 May 18th, 2018, 07:52
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#43
Quote:
Originally Posted by snotty View Post I happen to be from the widely panned community out here and the views expressed are l............................. .................. satisfaction in the profession..............There has been a generation shift in the way things happen across the society. Everyone is in a hurry to get things, do things, enjoy things and criticise them as well. RUSH! We do not see the level of dedication that was there in the older days in factory workers, in engineers, in............................ ........incompetence. Any adverse outcome a reason to abuse and at times assault the health care provider. Doctors tend to be defensive as well - order a battery of tests to cover all bases (and their a**es). I often see patients come in demanding for imaging tests, not realising that depression, addiction, stress, anxiety and marital discords are not going to show up in MRI and CT scans. But they feel that the doctor would miss something if he doesn't see 'inside' their heads. They need validation for their symptoms .............................. .........................the later and didn't turn up later. Now if hospitals and clinics have to be as well maintained and decorated as hotels and restaurants - it does cost money. (I still have to redo mine, even after 5 years of that rebuke!).
I understand that the feeling of anger is more because doctors/hospitals are often approached in times of dire needs and the charges are seen as extortion as you are in no position to look for alternatives at that time. So they need to be more considerate. But wouldn't it be too much to expect the doctors/hospitals to isolate themselves and stand out like an island......
Note - I think I am good with the short posts, the long ones get too philosophical!
Quote:
Originally Posted by RPG View Post I wanted to correct something I wrote earlier---I said "There is no concept of hospice in India". I did some googling, and that is not exactly true, in the sense that there are charitable agencies (not enough of them) that care for the dying poor. ............What seems to be absent in India is hospice care for the middle class and the rich---people who could afford good service either at home or in a facility, from staff experienced in end-of-life care and in emotional support for relatives. Many people have more money than judgement, and are at the mercy of predatory doctors and hospitals.
Some months ago in another thread I described a dying relative who ended up in a Mumbai hospital, getting first-class (and totally inappropriate) medical attention. Several specialists would drop by every day, say hello, and bill large amounts for their time. Every time he started to die they would revive him. Of course they force-fed him through the nose also. These predators should be stripped of their medical licenses.


Quote:
Originally Posted by capt_mahajan View Post Most people who can afford it try to provide some kind of care at home. Have seen a combination (depending on finances) of daily doctor home visits, so called 24-hour medical attendants (normally useless except as warm bodies in the vicinity of the patient) in shifts or qualified nurses (much more expensive but better), oxygen supply et al. I think there is stigma attached to 'abandoning' your near and dear to an outsourced facility still. This is also done for people with chronic but not necessarily immediately life threatening conditions. I did some of these things for both my parents, not for the stigma but because I had no real alternative; in any case, they would have been miserable in a hospice kind of place.If you can't afford it you just die however.
Quote:
Originally Posted by JOHNLORD View Post There have been cases in Kerala, where relatively posh hospitals in Kerala have given treatment even after the patient has died.
Quote:
Originally Posted by RahulDeva View Post It's a pan india thing. Patients are kept on ventilator support and meter keeps running.
Quote:
Originally Posted by RahulDeva View Post Not going into the details of this case but shouldn't relatives take some of the blame too? They can and should ask the doctor for a realistic assessment and then take a call.
I am writing this while sitting outside an IMCU where my father is admitted since the last 9 days. He isn't critical but due to his advanced age and a weak heart, minor problems keep cropping up. I have taken my decision. Will ask for a discharge as soon as the doctor comes.
[QUOTE=RPG;2088275]Yes, absolutely. But people never prepare in advance for such things, they have no comprehension. As stated by another poster, you have to be ready, you cannot think straight once things are happening.
For many people of some means, modern medicine is ultimately a curse, yet, until that point it is hugely beneficial.................... ... and nurses had been hired. These nurses took him to the hospital, probably in exchange for a payoff from the hospital.[/QUOTE

So I see almost all the complications that an ordinary person runs into by approaching the hospitals and also the problems faced by the doctors and hospitals and patients[QUOTE=snotty;2088209] have been discussed in detail in the above posts- may be I missed some earlier. But what is the way out or is there a way out is the million dollar question. How can we get out of this cog mire? I just wonder. Or are we going deeper and deeper into this? Hope Snotty will have some suggestions; he already has put in some and I wonder as a professional whether he with like minded fraternity will be able to begin some process through the IMA or such other organization.
#44 May 18th, 2018, 09:54
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#44
[quote=narayanvee;2088356][/U]







[QUOTE=RPG;2088275]Yes, absolutely. But people never prepare in advance for such things, they have no comprehension. As stated by another poster, you have to be ready, you cannot think straight once things are happening.
For many people of some means, modern medicine is ultimately a curse, yet, until that point it is hugely beneficial.................... ... and nurses had been hired. These nurses took him to the hospital, probably in exchange for a payoff from the hospital.[/QUOTE

So I see almost all the complications that an ordinary person runs into by approaching the hospitals and also the problems faced by the doctors and hospitals and patients
Quote:
Originally Posted by snotty View Post have been discussed in detail in the above posts- may be I missed some earlier. But what is the way out or is there a way out is the million dollar question. How can we get out of this cog mire? I just wonder. Or are we going deeper and deeper into this? Hope Snotty will have some suggestions; he already has put in some and I wonder as a professional whether he with like minded fraternity will be able to begin some process through the IMA or such other organization.
A synopsis of the state of things now: https://thewire.in/health/planning-t...t-all-possible
A hopeful sign: https://www.theatlantic.com/health/a...e-care/517995/
My thoughts: Most of us approach the last chapter of our lives with blinders on - behaving as if somehow we will escape the jaws of death, total denial. But failure to plan is to burden the ones you love most with the tasks they will find most excruciating.
First step is make your own wishes known for end-of-life care. Second is to get the same details from your loved ones. (Advice about how to have this conversation is here: https://experiencelife.com/article/h...conversations/ and many other sites.) Decide what the plan is if/when elders fall ill - the roles of family, doctors, hospitals, home care providers. Is there a hospice organization nearby or not? Does grandma want every possible medical intervention, or some, or none? Insurance?
Third thing is to make this all legal by completing notarized forms - Living Will, Durable Health Care Power of Attorney. (They can be downloaded here: https://compassionindying.org.uk/lib...decision-pack/)
Fourth thing is to make practical arrangements: Talk with the doctors (before the need arises) and be clear about agreed plans. The medical establishment may put its thumb on the scale in favor of treatment. Those legal documents are your best defense. They should be part of the medical record, but they should also be in your hands and widely spread around the family.
It helps a lot if the family is unanimous. When I was on an ambulance, we were delighted when a family had pasted the Do Not Resuscitate order to the patient's bedroom mirror where it could not be ignored. But when I was a nurse, my hospital would invariably defy the patient's instructions in favor of the family's wishes - they are the ones who will be around to sue.
Mother Teresa was roundly criticized for her palliative care model as she made no attempt to provide curative interventions, whether or not they were likely to succeed. Of course, she knew the dying person did not want to bankrupt his family on the way out, and took that into consideration. I guess part of the decision tree comes down to a cost/benefit analysis, and it's hard to put a value on quality of life. Good luck.
#45 May 18th, 2018, 11:19
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@Narayanvee

Quote:
I wonder as a professional whether he with like minded fraternity will be able to begin some process through the IMA or such other organization.
I don't know.. And I don't have too much hope from the professional organisations to police the fraternity with any meaningful consequence.. (atleast not until it threatens it's existence!!). The professional bodies are formed after an election. The voter bank - doctors. So steps that alleviate the voters are not high on priority even if required.
Next comes the question of the requirement (of policing the fraternity) - as mentioned in the previous post, loads of factors when you stand in the shoes of a doctor. For some reason gives that sense of entitlement. Especially if you are good at your work. (If you are not that good, then more of the unethical practice creeps in!).
Don't see changes happening unless policy and laws are made to make doctors responsible. But then enforcing the law is a completely different issue.
The system is in a pretty poor state. It begins with -
1. Deciding to enter the medical profession, put in loads of efforts for NEET and get entry. (Else the investment for NRI seat, which is pretty high - sets in the mindset of money being an important part of the profession.) Even merit seats in private colleges could set you back by 8-10 L a year. (upto 18L in some colleges)
2. 5.5 years to get the basic degree, if you clear in one go. Of this 4.5 years is education and 1 is internship. These 4.5 years make a huge difference in deciding how your approach to medicine would be. The teachers being a major catalyst to approach/ change of it. With the current changes in MCI laws, it is difficult for a clinician to last long in an academic set up. Too much focus on research - the clinician ends up in private practice. Also the payment by private medical colleges is a scandal. The availability of teachers is another - just 2 days back had a call to attend a MCI inspection as a faculty, despite not actually being a teacher there. Many of the ones remaining back in teaching jobs, often have not so great clinical acumen. (no generalisation, there are a few extraordinary clinician teachers). - Medical education has become a business as any other field of education. Quality is often the first victim of such transformation.
3. Post graduation - entrance exams attempted for 1-4 years. For every 100 MBBS doctors there is 1 clinical post graduate seat. (a rough estimate) Residency during post graduation can be in hell like conditions. Sleep for 6 hours once in 2-3 days, especially in government hospital settings. Poor work environment - seniors, patients, etc. Passing exams may take some time too. DNB degree is often got after 3-6 attempts.
Like I mentioned before this could go on more and more, still a few points to cover - but it gives a feel of whining, don't want to give it that tone.

Yes it is a struggle to become a doctor, a bigger one to settle down and provide adequately for your family, but the biggest struggle is to know how much is enough/sufficient!!

No, I don't see drastic changes happening in the present scenario if other things were to remain the same..

PS - At present I steer away from all professional organisations.
Last edited by snotty; May 18th, 2018 at 17:45..
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