Ways of dying

How do we die? Is it an event or a process? Does everyone die in the same way or are there different ways of dying? Even with humankind’s claims to gigantic strides in knowledge, death still remains one of the great mysteries for the living. And that makes it the subject of profound and perennial philosophical and religious enquiry. Modern medical science, however, had no option but to engage with it in its bodily form and try to define the precise nature of the process of death. Things were rather easy when death was equal to stoppage of the heart. But inevitably, the world of medicine with its keen sense of observation and constant yearning for scientific reasoning, recognised, somewhere in the middle of the last century, that the brains of a set of individuals hooked onto support systems in intensive care units were dying first, inevitably followed by the heart after some time. The tremendous progress in the science of resuscitation, organ support and intensive care while saving many lives resulted in an increasing number of such individuals, who were soon termed “brain dead” but whose hearts were still beating. The damage to the brain was irreversible and complete and inevitably, the heart had to follow within hours, or sometimes days.

A Fine doctor

I met Jonathan Fine for the first time in 2011. He was to travel back to Boston through Mumbai after a stint in Chattisgarh, where he had volunteered with Jan Swasthya Sahayog, the well-known rural hospital near Bilaspur. A friend suggested that since he was a doctor who had done pioneering work by setting up the renowned organisation Physicians for Human Rights, we should arrange a talk by him for medical students. A lecture was thus organised at my alma mater, the GS Medical College & KEM Hospital, where Jonathan spoke on “Why should doctors engage with human rights?” In his characteristic blunt style, rather than talk about his past, he exhorted the audience to visit Chattisgarh and see the severe inequities he had witnessed.

The Supreme Court of India on euthanasia: Too little, too late

On Friday, March 9, 2018 the five-judge Constitution Bench (CB) of the Supreme Court of India (SCI) chaired by Dipak Misra, the Chief Justice of India, pronounced its judgment (1) (henceforth CC judgment) granting, for the first time in India, legal recognition to “advanced medical directives” or “living wills”, ie, a person’s decision communicated in advance on withdrawal of life-saving treatment under certain conditions, which should be respected by the treating doctor/s and the hospital. It also reiterates the legal recognition of the right to “passive euthanasia”; and draws upon Article 21 – the right to life – of the Constitution of India (henceforth Constitution) (2) interpreting robustly that the “right to life” includes the “right to die with dignity”. Justices Misra and Khanwilkar disposed of the writ petition filed in 2005 by Common Cause (3) (henceforth CC petition) saying, “The directive and guidelines shall remain in force till the parliament brings a legislation in the field” (1:p 192).

Verrucous carcinoma at ileostomy site / Carcinoma verrucoso em local de ileostomia

ABSTRACT We describe of a case, a 50 year old male who was operated for carcinoma of the descending colon and diverting loop ileostomy, developed a fungating lesion in mucocutaneous junction of ileostomy after one year which on histology revealed to be a Verrucous carcinoma.

RESUMO Descrevemos um caso, homem, 50 anos, que foi operado para carcinoma de cólon descendente e ileostomia em alça para desvio. Transcorrido um ano, o paciente desenvolveu uma lesão vegetante na junção mucocutânea da ileostomia; a histologia revelou ser um carcinoma verrucoso.

Healing and dying with dignity: Where does India stand.

The articles in this special issue have emerged from work towards the sixth National Bioethics Conference entitled “Healing and dying with dignity: Ethical issues in palliative care, end-of-life care and euthanasia”. These contributions from physicians and social scientists touch upon three closely linked concepts, and raise complex ethical issues that must be faced by patients and their families, as well as by healthcare providers.

MLK

Heady with an inflated sense of achievement on acquiring a medical seat, a new medical student often gets a rude shock in the morbid world of human anatomy. The unclaimed corpses of the homeless who inhabit our cities laid out on dissection tables, human parts stripped of their coverings, the putrid smell of formalin, and the agonisingly long lists of tendons, muscles, bones and vessels do not fit the romantic image of medicine that they had. In every batch of new entrants, there are a few who feel so revolted by what they see in the anatomy dissection hall that they opt out of the course, or at least seriously contemplate doing so. All in all, anatomy can be boring and demoralising.

Deceased organ donation in India: where do we go from here.

Transplantation represents one of the best examples of the scientific achievements of medical science. However, its success has also led to some of the fiercest ethical challenges in modern medicine. Partly as a response to the uncovering of a flourishing clandestine kidney trade, the Central government promulgated the Human Organs Transplant Act (HOTA) in 1994. HOTA, along with its amendments, was a step forward in recognising concepts such as brain death. Nevertheless, there are numerous ethical challenges still to be resolved, particularly with regard to consent, incentives to donors and families, and equitable distribution of donated organs.

Towards deceased organ donation in Asia: negotiating the challenges.

In the developed world, deceased donation is now a well-established source of organs for the unfortunate sufferers of end-stage disease of vital organs. As the science of transplantation grows and the success of transplantation improves, the rest of the world is keen to offer this life-saving procedure to its citizens. As Asia surges forward in attempting to meet the rising demand for replacing failed organs, efforts across the region to develop viable deceased donor programmes are visible. However, according to reports by contributors to this special theme issue, these efforts have met with limited success.

Fast-track surgery in India.

Fast-track surgery or ‘enhanced recovery after surgery’ or ‘multimodal rehabilitation after surgery’ is a form of protocolbased perioperative care programme. It is an amalgamation of evidence-based practices that have been proven to improve patient outcome independently and exert a synergistic effect when applied together. The philosophy is to treat the patient’s pathology with minimal disturbance to the physiology. Several surgical subspecialties have now adopted such protocols with good results. The role of fast-track surgery in colorectal procedures has been well demonstrated. Its application to other major abdominal surgical procedures is not as well defined but there are encouraging results in the few studies conducted. There has been resistance to several aspects of this programme among gastrointestinal and general surgeons. There is little data from India in the available literature on the application of fast-tracking in gastrointestinal surgery. In a country such as India the existing healthcare structure stands to gain the most by widespread adoption of fast-track methods. Early discharge, early ambulation, earlier return to work and increased hospital efficiency are some of the benefits. The cost gains derived from this programme stand to benefit the patient, doctor and government as well. The practice and implementation of fast-track surgery involves a multidisciplinary team approach. It requires policy formation at an institutional level and interdepartmental coordination. More research is required in areas like implementation of such protocols across India to derive the maximum benefit from them.

Satpal Dang – a personal memoir

In the early 1990s when this journal was in its infancy and struggling to establish itself, I used to enthusiastically show it to all those who I thought would be even remotely interested. I always carried copies and passed them on to colleagues, friends and family members. I then requested them to read it, spread the word among their doctor contacts and of course, solicit subscriptions. Many of them would look at the journal and say the usual nice things, and it often ended there.

Fire in a hospital.

On December 9, 2011, in a shocking and gruesome incident, perhaps the worst of its kind in India, a massive fire broke out at the AMRI Hospitals, a large private speciality institution in Kolkata and consumed 93 lives. Hapless patients in wards and intensive care were suffocated and charred to death as local fire containment measures were nonexistent and fire fighters could not enter the narrow lane leading to the hospital .There was a huge media outcry over the incident and finger pointing by local politicians. As a fallout of the incident, six directors of the hospital, including two senior doctors and four others who happen to be leading Kolkata industrialists, were arrested for abetment.

Major hemobilia – experience from a specialist unit in a developing country.

Background and Aim: Hemobilia is a rare but potentially life threatening problem, which can be difficult to diagnose and treat. In the last few decades there has been a change in the etiologic spectrum and management of this problem in the West. The aim of this study was to analyze the etiology, clinical features, management and outcome of major hemobilia in a tertiary referral centre from western India. Methods: A retrospective analysis was undertaken on 22 patients (16 males, 6 females; mean age 39 years, range 13 to 74) who presented with major hemobilia over a 5-year period. Results: The etiology was iatrogenic in 13 patients (percutaneous transhepatic biliary drainage 8, post laparoscopic cholecystectomy 3, endoscopic retrograde cholangiopancreatography 1, and liver biopsy 1), liver trauma in 6 and liver tumors in 3 patients. Twenty patients presented with gastrointestinal bleeding (melena 20 patients, hemetemesis with melena 8 patients), 5 with jaundice and 8 had fever. Abdominal angiography was performed in 20 patients. Angiography revealed pseudoaneurysm of the right hepatic artery or its branches in 14 patients, left hepatic artery in 2, an arterio-biliary fistula in 1, tumor blush in 1 and the source could not be located in 2 patients. Seventeen of the 22 patients were treated with radiological intervention, 3 required surgery (liver resection for tumors 2, laparotomy for venous collateral bleeding of portal cavernoma 1) and two were managed conservatively. Radiological intervention involved embolisation with coils and/or glue in 16, and chemoembolisation in 1 patient. Sixteen of 17 patients responded to embolisation. Overall there were two deaths. Conclusion: The spectrum of hemobilia seen in India is now similar to that in the developed world with iatrogenic causes being the commonest. Interventional radiology can treat a majority of patients reducing the need and morbidity associated with surgery.

Ethics, equity and justice: a view from the belly of the beast.

First of all let me begin by saying that I feel deeply honoured and humbled at being asked to deliver this talk at this inaugural plenary of the NBC 2010.