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.