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Introduction

Critically ill patients need treatment either in an ICU or a CCU or treatment by a specialist in a well equipped and sufficiently staffed hospital. There are many ethical issues which remain unattended. This article throws light on various ethical aspects which should be considered while treating a critically ill patient.

Lack of Guidelines

If we look at the state of ICUs and CCUs around us we’d agree that a majority of them are ill equipped and understaffed. At present, there is no regulatory body responsible for laying down guidelines for the construction and establishment of an ICU and also for its further inspection. So, anybody who has some medical qualifications (not necessarily allopathic) starts an ICU. Mostly, it is deficient in space and equipment. A well known example is that of a CCU and Cardiac Research Center staffed by final year MBBS students of a local private medical college!

So, the first and foremost task which should be seriously taken up by the State Medical Council, the (so called) regulatory body of the medical profession is to lay down some guidelines in this respect.

Preference of Treatment

The Declaration of Geneva states: “I will not permit consideration of religion, nationality, race, party politics, or social standing to intervene between my duty and my patient. But, it is frequently seen that whenever there is shortage of beds or equipment in an ICU, the financially or politically influential patient gets preference in admission, treatment or equipment over a common man who may be in greater need and waiting for treatment. So, in such situations, the “First come first served” policy should be strictly followed without taking into account any other factor.

Iatrogenic Errors and its Disclosure

In a study conducted by S. K. Maithel, comparing the situation about iatrogenic errors and “Truth telling” in India and the US, it is clearly evident that a majority of Indian doctors never reported the medical error and most of them did not even know if any such office/department where a medical error is to be reported existed at all.

But if we look at the Indian scenario, the results of the study are not at all surprising. Most of Indian doctors even do not feel the necessity to discuss the ailment of the patient with him or his relatives, then how can we expect them to discuss the errors (read – blunders) which they have committed? Moreover, it is not possible to compel a doctor to do so.

One alternative will be that the judiciary should liberally use the doctrine of ‘Res ipsa loquitar’ in all cases where medical negligence is alleged. It means ‘It speaks for itself’ i.e. if the damage suffered by the patient is such that it could not have happened without medical negligence, then instead of the patient requiring to prove the doctor’s guilt, the doctor has to prove his innocence. So, to put a check on the conspiracy of silence prevailing in the medical profession, the benefit of this doctrine should be liberally given in all cases of alleged medical negligence.

Diagnosis of Death

In case of critically ill patients, when it comes to diagnosing the death of such patients who are on ventilators, due to a defect in the Human Organ Transplantation Act, the diagnosis of brain stem death can only be made in those patients who have consented for removal of their organs for transplantation. In all other cases, there suscitation process must continue till the heart stop beating. This defect must be corrected with immediate effect to prevent the ethical dilemma which arises every time in cases of non donor brain stem dead patients.

Confidentiality and Disclosure

The necessity of confidentiality in medical practice has not been properly valued until now in India. But, in the West due to the successful allegations by patients against doctors for not maintaining professional secrecy, the condition is far better. In India, patients also do not bother about this aspect except when it affects his treatment as in cases of an HIV positive patient. When the doctor discloses the HIV positive status of the patient, the news immediately spreads among the medical and paramedical staff, the relatives and also other patients occupying that ward. This affects the attitude of all these persons towards him and may finally result in his being “Thrown out” of the hospital, thus affecting treatment.

Besides, most doctors do not receive formal training to discuss a particular situation with the patient or his relations and this is more true when it comes to disclosure of bad news like the patient being afflicted with cancer, AIDS or any terminal illness.

Here, the dilemma is whether one should conceal the information from the patient and give him false hopes or explain in detail the diagnosis, stage of the disease, side effects of treatment and prognosis of the patient and in the process upset the patient as well as his/her family or should one take relatives in confidence and keep the patient in dark?

Breaking bad news therefore requires skill in communication and an understanding of the patient’s mind and preferences. Dr. K. M. Mohandas suggests : “Always give the patient hope, even when death seems at hand. He believes that if your time has not come, even your doctor can not take you away”.

Euthanasia

At present, no statistics are available on the subject. But, euthanasia is being practiced at present even in India! To deny this is like saying that abortions were never carried out before it was legalized. If we take a public opinion poll in India, we will arrive at a similar situation to one in California, where 70% of the electorate favored the legislative initiative for euthanasia.

So, instead of wasting time in useless and unfruitful philosophical discussions, the relevant statute laws framed elsewhere should be studied by a committee of experts and euthanasia should be legalized in India as early as possible.

Force Feeding

Force feeding a person who has voluntarily stopped taking any nutrition creates doubts among physicians. The dilemma is whether to respect the patient’s wishes and let the situation take its own course or to give parenteral nutrition to the patient against his wishes and save his life. The declaration of Geneva states that health of the patient should be the first consideration of the doctor. Thus, according to it, the doctor should proceed to force feed him against his wishes.

However, many feel that the doctor’s action should be guided by the Declaration of Tokyo adopted by the 29th World Medical Association in October 1975. Clause V reads: “Where a prisoner refuses nourishment and is considered by the doctor as capable of forming unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she should not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner”.

Care of Dying Patients in Hospital

Mills Mina et al in their paper describe a prospective study of 50 dying patients in the west of Scotland. The paper commences with the sentence: “Though most terminally ill patients indicate a preference to die at home…, more than 60% of all deaths occurred in an institution”. The conclusion is equally riveting. “Care of many dying patients observed in these hospitals was poor. We need to identify and implement practical steps to facilitate high quality care of the dying.”

Thus a thought should be given to this problem. This, of course, is a foreign study and the situation might differ in India. But when the prognosis of the patient is fully known and there is no provision of “Mercy killing”, the patient should be discharged instead of continuing to extract large sums of money from the already aggrieved family till the end and even after. One should adopt the policy of, “Always treat the family, not just the patient”.

Second Opinions & Referal

It is the right of the patient to seek a second opinion whenever he desires, and it is the duty of the doctor to refer the patient to another colleague whenever the situation so demands. But, it is a known fact that doctors for sake of monetary gain or for fear of lowering their reputation, do not consider timely referrals and the case ends in a disaster. The patients also do not know the right to getting a second opinion. If a patient asks his treating doctor regarding it, he should honor the patient’s wish rather than take it as an inability to keep the faith, so vital to the contract. The doctors themselves should understand their limitations and should not go beyond their skills. They should lay for themselves some guidelines with respect to referral of patients and issuance of second opinions. These are some of the ethical principles that doctors caring for the critically ill should bear in mind. This will not only prevent litigation but also improve the quality of patient care.