Indian Journal of Medical Ethics

How do medical students learn to make impossible decisions every day? They can share their problems with their colleagues and seniors, and learn decision-making skills which will carry over into their practice once they graduate. At the MGIMS, a group of residents and interns has started informal discussions of case study scenarios. The idea is to encourage students to discuss their dilemmas, identify the reasons for their decisions and thus clarify the decision-making process. The first case study was based on a real life scenario at the MGIMS.

TG, a 58-year-old man, was diagnosed as suffering from motor neuron disease, an incurable and degenerative neurological ailment. He lived in a village 600 kms away from our hospital. His son and daughter-in-law took care of him. They had brought him to our hospital a month earlier. The disease had paralysed the muscles of his larynx and pharynx and though he could breathe on his own, with difficulty, he could neither speak nor swallow, and was drowning in his own saliva.

TG was admitted to the ICU and an opening was made in his windpipe to enable us to periodically suck out the secretions. His breathing distress was greatly reduced following this operation, but this relief was short-lived; four days later he aspirated his stomach contents into his lungs and was put on a mechanical ventilator.

TG's days were already numbered when the diagnosis was made. The most recent crisis had hastened his deterioration. We had not discussed with him whether he wanted to be kept alive in a severely debilitated state. He was in obvious distress. He could understand everything said to him but he was unable to speak.

His adult son and daughter in law were designated as surrogate decision makers. Both were educated and earned good salaries. The son had rushed his father to the hospital without asking for a leave of absence and as soon as his father stabilised he went back to work. Alone, his wife found the ICU environment and her father-in-law's illness too stressful. She broke down and had to be referred to our psychiatrist who admitted her to his unit for a day. The son was sent for and came back immediately.

In the course of a conversation between the ICU team and the family, the son insisted that his father be placed on the ventilator for "as long as possible". In the next few hours, the residents and the consultant met several times with TG's family members to negotiate a plan acceptable to all. We were aware that the illness had created issues that the family needed time to work through. The family members knew that the patient would not live long, but they were not ready to give up hope. They also wanted to do everything possible for their father.

We explained to the family what the patient was heading for and how he was likely to fare. We also hinted that we might have to withdraw life support from TG should a more deserving patient need it.

The next day the son walked up the senior doctor in tears and communicated the family decision. "My father, a symbol of strength, and the fountainhead of spirit, has always been a role model for me. It is very painful for me to see him die like this, slowly. I feel so helpless. Please help me bring an end to his misery. We would like you to switch off the ventilator and would like our father to breathe his last in our village."

The patient was shifted from a mechanical ventilator to an ambubag 'powered' by his relatives who managed to keep him alive during the eight-hour-long journey. The patient died soon after he reached his village.

This report was related to two residents and three interns in the department of medicine. Various questions were raised in the course of a discussion. Here, we summarise the responses to the following questions: What would be the best way to bring an end to this impasse? What would you have done if you were the doctor? What if you were the medical superintendent? Finally: this patient has been put on the only ventilator available in the ICU. What would you do if a 15- year-old boy bitten by a snake presents with respiratory paralysis and needs the ventilator?

Most people felt that in an ideal situation the doctor should withdraw life support and prepare the relatives for the patient's death. However, it is not clear how life support could be withdrawn; as two participants pointed out, this would be an illegal act.

Most participants recognised a central flaw in the events as they were described -- the patient's own wishes were never sought. When making this decision, the doctors were concerned with the family's needs and demands. "The account indicates that the patient was able to communicate, even if he could not speak. In these circumstances, there is no question of asking for the father to be put out of his misery," said Mamta, an intern. "The patient was conscious and aware of what was going around him so the decision to withdraw all life support does not rest on the treating physician or his next of kin," said Samir, an ICU resident. "The son is justified in wishing his father a dignified death, but he must take his father's consent -- both relatives and doctor should respect the patient's wishes." said Sonali, an ICU resident. The decision to transfer the patient to an ambubag was described as "rash" by Darshana.

In effect, by transferring the patient on to an ambubag, the decision to put an end to the person's life was made not by the doctor but by the relatives - with the doctors' acquiescence.

Samir argued that there was no logical way out of this impasse. He "would counsel the patient and family, and acknowledged that the patient's family might be worried about the financial implications of prolonged intensive care. However, the doctor cannot withdraw life support for administrative reasons. "The options do not change even if I were medical superintendent."

On the other hand, it was difficult to resolve this basic principle of patient autonomy with the need to make hard decisions. What would they do if a victim of snake-bite - an eminently reversible crisis -- came in needing the respirator? Most felt it would be appropriate to take the older man off the respirator and turn it over to the patient with respiratory paralysis. "If there is only one ventilator I would provide it to the 15-year-old boy who has better chances of survival," said Mamta.

Others suggested alternatives to the ventilator, but here, too, there were two views. Should a patient already on the ventilator be put on an ambubag because a patient with better chances of recovery needs it? "If a snake-bite victim is admitted with respiratory paralysis, I would have withdrawn the ventilator with the consent of the relatives and put the patient on ambu bag," said Samir.

On the other hand, "If there is only one ventilator in the hospital and a young patient is admitted needing ventilator support, I would give him primary treatment and refer him to another hospital. I don't think it makes sense to taking a ventilator-dependent patient off the ventilator to put another patient on," said Kavita. "Should age be a criterion in such decisions? I don't think so, but I am confused about this." The suggestion that age might be a criterion in deciding a person's 'fitness' for the ventilator raises a subject which does not seem to have been discussed - what criteria are used by the ICU for putting a person on intensive care? The first, generally accepted, criterion is whether the condition is reversible. In this case, people might have asked whether TG's condition merited his being put on the ventilator in the first place.

Others felt that the decision was the doctor's, not the patient's family's, and not the administrator's. And the doctor's duty is to do the best she or he can, for as long as possible. "The doctor should be allowed to make the final decision. "I would have talked to relatives about the nature of the disease, its progressive course, about the possible options of treatment and the outcomes. I would have respected the patient's and the family's wishes in deciding the further palliation and treatment."

Another area of discussion was the need to help relatives come to terms with their loved one's imminent death, and to understand that there is nothing wrong in wanting a dignified death rather than prolonged treatment. Often relatives request aggressive treatment in futile situations because they feel that asking anything less would suggest they did not love the person enough.

Interestingly, no one picked up on the coercion implied in telling relatives that "we might have to withdraw life support from TG should a more deserving patient need it." One resident stated, "If a snake-bite victim is admitted with respiratory paralysis, I would have withdrawn the ventilator with the consent of the relatives and put the patient on ambu bag." "If I faced a situation in which another, recoverable patient was admitted urgently needing ventilator support, I would have discussed the problem with the patient's relatives," said Sonali. "I would have withdrawn the ventilator from the patient and provided to the snakebite patient." It would have been interesting to explore the notion of consent in such circumstances.