b. Patients as recipients of discordant care
Case records, available from the hospital are schematically presented to highlight chaos, conflicts, and tensions that surrounded dying patients in absence of well-coordinated MDTs.
Fig. A: Case of Mrs Soma (70 years; Ca Lung with bone metastasis)
(Figure A)
The case of Mrs. Soma highlights two important issues: firstly, the structured pattern of caregiving in the hospital did not exempt the frail aged dying patient from undergoing aggressive cardio-pulmonary resuscitation (CPR). Moreover, most of the physicians, who were involved in the treatment trajectory of Mrs. Soma, were unfamiliar with her treatment preferences and choices. Such abrupt and short-duration involvement of the physicians with the treatment trajectory possibly made the dying patients feel discomfort. Unfortunately, Soma’s preference was only known to the primary physicians, who did not communicate it to the rest of the team members. Worse still, the primary consultant of the patient could not be reached over the phone. This compelled the on-duty physicians to make crucial medical decision of resuscitating the gasping patient; it not only dishonoured the family’s request to not to resuscitate but violated patient’s autonomy also!
Fig. B: Case of Mr Gopal (82 years; COPD and kidney failure)(Figure B)
In this case, too, the patient was compulsorily subjected to aggressive treatment at the end-of-life. As a result, the patient had to follow strict treatment regime characterised by series of diagnostic tests, ICU admission, and multiple CPR attempts. Unfortunately, the procedure could not save the patient, who eventually died. In fact, Mr. Gopal died without proper end-of-life care. Although he was treated by a team of doctors, none seemed to consider his advanced age and multiple morbidities as criteria to stop aggressive treatment. Moreover, like the previous case he too was transferred from one specialist to another who had little coordination among themselves. Unfortunately, the nephrologist under whose supervision, Mr. Gopal was admitted, was nowhere around during his death. Gopal’s family too were not around his deathbed. Such a situation rarely guarantees a continuum of care. It also indicates physicians in their overwhelming enthusiasm to resuscitate patients, ignores symptoms of the impending death.
Fig. C: Case of Mr Kumar (72 years; Metastasis in the right pyriform sinus)(Figure C)
Mr. Kumar’s case also ends with conflict between family members, physicians and the hospital administration on the issue of ICU admission. While the hospital authority and the physicians insisted for ICU admission as per the treatment protocol, the family members strongly opposed the decision. This soon led to chaos and scuffle around the deathbed of the patient. The incident was soon over but took a severe toll on the patients’ physical condition who suffered a massive cardiac arrest. None seemed to take into consideration the patient’s choice. As a result, Mr. Kumar died alone in the ICU; it was certainly not a ‘good death’ by any means.