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End of Life Decision

Shared from Facebook page Learning Critical Care Medicine (posted on 18th May 2015).

" marte hain aarjoo me marne ki
  maut aati hai par nahi aati "
                - Mirza Ghalib

Aruna Shanbaug officially died today at KEM hospital Mumbai. She was in Permanent Vegetative State (PVS) for the last 42 years. During these years she had become a living skeleton, though she pulled through this long because of effort, love and care of her fellow nurses. She did not develop a single pressure sore.

Infrequently miss Shanbaug used to transform into news headlines as she became synonym for End of Life Care debate in India during last many years.

As there was no clear law regarding End of Life Decision ( EOLD) in India, public interest litigation was filed in 2009 in Supreme Court to relieve Aruna of her sufferings.

Court arrived to verdict in 2011, affirming that Aruna is in PVS. Decision to withdraw life support measures can be taken by parents/ spouse/ close relatives or in their absence surrogate decision maker (people taking care). However approval from concerned High Court has to be taken before proceeding with the decision.

But surrogate decision makers ( staff of KEM hospital) decided not to withdraw treatment, probably because of emotional factors.

End of Life Decision ( EOLD) does not translates to terminating life. EOLD means Right to Die with Dignity.

Right to live also encompasses right to death with dignity.

With the advent of life support machines coupled with advance knowledge, patients with critical illness and hopeless outcome are treated aggressively, prolonging the natural process of death. The gap between life and death has been blurred. Therefore the end result achieved is physical, emotional and financial suffering on the part of patient as well as relations. On the other hand scarce resources are wasted and potentially salvageable patients are denied bed.

EOLD  comprises of 3 different pathways. DNI/DNR (do not intubate/ do not resuscitate),  treatment Withholding and treatment Withdrawing. DNI means not putting endotracheal tube and invasive mechanical ventilation. DNR implies not doing CPR (cardiopulmonary resuscitation) in the event of cardiac arrest. Not escalating existing treatment, if patient further deteriorates, is Withholding of treatment. Pulling off the life support measures is Withdrawing of treatment.

The soul of EOLD is ensuring that patient must not feel pain.

Also remember that EOLD does not mean that patient has to die. Purpose is to put a cap on futile treatment. It is possible that patient may not need the treatment/ intervention and may survive to home.

Who can decide EOLD:
Advance directive is patient decision to choose EOLD pathways. If there is no advance directive then surrogate decision makers can choose the pathway. Surrogate decision makers are parents/ spouce/ siblings/ other close relatives. If there are no relation, people taking care of the patient can decide.
There could be possibolity of malicious intention of relatives in approving for EOLD, which creates legal hurdle.
If relations are not willing for EOLD, treating physician can decide EOLD,  if they opine about futility of treatment ( weighing the treatment and probable outcome).

Again remember that there has to be clear legal provision regarding who can decide EOLD, if there is no advance directive.

Now certain terminologies which are no more used in EOLD.

Acive EUTHANASIA: providing patient some lethal drugs to end life, patient consumes/ injects himself. It is crime in most countries barring a few.

Passive EUTHANASIA: Not giving the needed treatment to prolong life. It is same as Withholding treatment.

PHYSICIAN ASSISTED SUICIDE: Physician himself provides patient the drug to end life. Crime in most countries barring a few.

Finally EOLD is not a new concept.

" first I will define what I conceive medicine to be.
In general terms, it is to do away with the sufferings of the sick,
To lessen the voilence of their disease,
And to REFUSE TO TREAT THOSE WHO ARE OVERWHELMED BY THEIR DISEASE,
realising that in such cases medicine is powerless"

                    --The Hippocratic Corpus

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