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Euthanasia -- offering patients the right to a dignified death

A doctor's dilemma regarding how to deal with patients and how to deliver bad news.

Written by Dr Umanath Nayak |Published : March 9, 2018 11:06 AM IST

My first impression of Saida Banu was not very flattering. She appeared unable to grasp the seriousness of my words and the urgency of the situation. In retrospect though, I suppose I was also to be blamed for not being forceful enough when I first explained to her the condition of her mother and the need for immediate surgery.

Her mother had a large goitre compressing her trachea (the wind-pipe) that had also paralysed her right vocal cord. This indicated a high probability of malignancy. Saida challenged my diagnosis of cancer as her mother had been carrying the goitre for the last twenty years, it had never bothered her much in the past and maybe it was not as serious as I seemed to believe. I explained patiently that long-standing benign goitres were known to suddenly change their behaviour and this must have happened in her mother s case. She did not seem convinced and requested for two weeks time as it was the month of Ramadan and admitting her mother would have been inconvenient for her and her family. I reluctantly agreed. (Read: You may have a thyroid problem and not know about it!)

She reported the next day after Eid. To my shock, the goitre had doubled in size in this period and the old lady was now struggling to swallow even liquids and choked whenever she tried. Even more importantly, it appeared that the lady now had lost all will to live and implored upon her daughter to take her back home and not admit her to the hospital. But ridden by guilt, Saida got her admitted immediately and implored me to do whatever I could to make her mother better. I had a feeding tube inserted through her nose to administer her much-required nourishment and instituted other measures to improve her condition. She appeared to improve somewhat, but a couple of days later had a severe bout of airway obstruction in the middle of the night and the duty anaesthetist had to put in an endo-tracheal tube and get her shifted to the surgical ICU to be put on an artificial respirator.

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The next morning I met the family -- Saida, her siblings and other senior members to discuss the next course of action. I explained that the behaviour of her mother s goitre indicated a very aggressive form of thyroid cancer known as anaplastic cancer and any treatment offered at this stage may be futile. We could attempt to surgically remove it, but the chances were high that it would recur very fast. But Saida was adamant. She refused to accept that her mother had an incurable condition and wanted to try and attempt surgery, especially since a needle biopsy done just after admission had failed to confirm the presence of cancer. She asked me what other options did her mother have and when I answered none, she said that if surgery offered her mother even a 5% chance of recovery, she was willing to take the risk. She wanted to be able to tell herself that she had tried whatever possible was in her means to help her mother get better and did not wish to be burdened forever with the guilt of not having done enough.

As they appeared to come from a lower middle-class background, I decided that it was time to get into the logistics of the treatment costs and find out if she was aware of the financial implications of her mother s treatment at a corporate hospital. Saida was the eldest in the family and had single-handedly raised three siblings. In her early thirties, she had not married just in order to take care of the family. All of them were extremely attached to their mother and were willing to go to any lengths to see her alive for a few more months. When I asked her how she planned to arrange the finances, she said that she would manage. When I probed deeper she said that she had some savings after all these years of working and if need be, would sell off her jewellery and other assets without a second thought if the need arose. For the first time, I felt uncomfortable with her statements. Here she was, willing to sacrifice all that she had managed to save after years of toil, jeopardise the financial security of her siblings and herself on a treatment which at best offered her mother maybe a few months of life, most of which would either be spent in the hospital or travelling to and from the hospital. I tried my best to convince her otherwise, but she was resolute. Her uncle and other senior members of her family tried explaining what I was attempting to say, but she did not relent. I could have refused to treat her mother, but she was already under my care, on a ventilator and there appeared no other way out especially since the CT-scans did indicate a tumour that theoretically could be taken out surgically. But my instincts told me otherwise. (Read: Are YOU at risk of thyroid disease?)

I had a discussion with the rest of my team as well as members of the anaesthesia and critical care team and the general opinion was that if the family was willing we should give it a shot and I went ahead with her surgery, in the hope that we could relieve her airway obstruction and get her out of the respirator and the ICU. We managed to get most of the tumour out successfully and the final pathology did confirm my doubts; it was the worst kind of thyroid cancer the anaplastic variant. She was in the ICU for two weeks, but then recovered sufficiently to be shifted to the regular ward. A week later I noticed that the tumour in her neck had started re-growing, now at an alarming pace. Along with this, her condition worsened and she was back in the ICU and on the respirator. Saida finally accepted that there was nothing more that she could do for her dear mother and a few days later, agreed to have her taken off the respirator. She was taken home on an ambulance, where she breathed her last that same night. It appeared that Saida s insistence on treatment had resulted not only in unnecessary suffering for her ailing mother but financial ruin for her and her siblings!

Later on, looking back at the case, I started wondering if I could have managed things differently. I could have refused to admit her under my care, but that would only have resulted in Saida taking her mother to some other hospital for treatment. I could have refused to operate on her after she was intubated and on the respirator, citing the futility of surgery and her poor condition. It would have meant that the lady would have languished in the ICU, unconscious and on artificial respiration and other supports until her heart gave out or until the family s finances ran out. Could I have convinced Saida and her family that the best thing to offer her mother would be non-voluntary euthanasia, a physician-aided painless and humane death?

Euthanasia or mercy killing is by definition the practice of intentionally ending a life in order to relieve pain and suffering . It generally refers to death, which is induced by a physician at the request of a patient who has intractable pain or is suffering from a terminal illness. But this description is vague and arbitrary and different countries adopt different parameters to define euthanasia and to give it legal sanctity. Euthanasia can be voluntary (where the patient gives consent to it), or non-voluntary where the patient is unable to give consent due to various reasons. Active euthanasia involves the use of lethal injections or substances and the Netherlands was one of the first countries to legalise active euthanasia in 2001. Belgium and Luxembourg followed. While active euthanasia per se is illegal in the United States, a modification of it, termed as assisted-suicide has legal sanction in the U.S. states of Oregon, Washington, Montana and Vermont as well in countries such as Switzerland, Germany and Japan. This is slightly different in that while in euthanasia the onus lies with the physician to administer the lethal drug, in assisted-suicide the individual himself on the prescription or advice of a physician does the administration. It is believed that assisted suicide has lesser scope for misuse than euthanasia, but in essence both euthanasia and assisted-suicide adhere to the same philosophy i.e. alleviation of unnecessary suffering and hastening death. The state of Oregon legalised assisted-suicide in 1997, but here as well as in the other U.S. states, which practice it, only bonafide residents of that state are eligible to request for it.

In contrast, passive euthanasia involves withholding of life support mechanisms such as nutrition, antibiotics or respiratory support and is widely practiced all over the world in different forms. Even in India, though the term euthanasia is not used due to its legal ramifications; some form of de-escalation of therapy to passively assist in the death of patients who are terminal or in coma is practiced in many hospitals with the consent of the family. This generally involves not using antibiotics or blood pressure supporting drugs, which are crucial for maintaining the life of patients on a respirator in the ICU. Though more drastic measures such as stopping nourishment to the patient or disconnecting the patient from the respirator are practiced in rare cases, these were against the law in India and the hospital/physician was liable to prosecution in these cases until the ruling by the Supreme Court which legalised passive euthanasia in 2011, following its hearing in the case of Aruna Shanbaug. Though the Supreme Court refused permission to grant the request to stop nourishment to Aruna to aid her death on humanitarian grounds, it laid down certain guidelines for the practice of passive euthanasia in our country.

Physician opinion is divided on the acceptance of active euthanasia as a method to relieve patient suffering. While many believe that euthanasia by definition goes against the basic tenet of a physician s goal - do no harm , the modern version of the Hippocratic oath does give the physician the power to take life under extraordinary circumstances, provided it is done with humbleness and awareness of the purpose. Relieving unnecessary suffering is also one of the physician s responsibilities to his patient. A survey in the United States on active euthanasia gave a mixed verdict with almost equal numbers supporting and opposing it. A similar study in the U.K. showed majority (64%) supporting active euthanasia if extreme circumstances warranted it.

Would I have resorted to this extreme step in the case of Saida s mother if the law condoned it maybe!

The views expressed here are the author's and not necessarily that of

Photo source: Shutterstock (Image for representational purpose only)

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