A Time to Let Go

Aruna Shanbaug, who worked as a nurse in a Mumbai hospital was raped and strangulated by a fellow hospital employee in Nov 1973. It has been more than 37 years that she has been living in a vegetative state in a Mumbai hospital. She is forced fed by her care providers. She can not express herself and her medical team believes that she has no chance of any medical improvement. Pinki Virani a Mumbai based journalist and author, who has written a book on Aruna has now moved the Supreme Court of India, requesting that she be allowed to die peacefully.

Euthanasia or mercy killing is illegal in India. The courts have acknowledged the complexity of the issue many a times earlier as well. While the courts may debate the pros and cons of legalizing mercy killings, many people in the medical world believe that allowing terminally ill people to die peacefully is as much a part of good medicine as it is to fight disease. A good doctor knows when it is time to give up and accept defeat against a disease and let the patient go. Prolonging a patient’s agony by keeping him alive in a vegetative state, using machines, which replace human organs is very wrong.

Thus, the critical issue here is when does one decide that time has run out for a patient and accept that nothing more can be done. Can a doctor say with utmost certainty that there is nothing that medical science can do to pull a patient back from the brink? When do we pull the plug and feel no guilt about letting a dear one go? This is where most doctors hesitate, hold on for a little longer, clutch at straws such as minor improvements and hope against hope that a miracle may happen. Doctors too are humans, they are trained to fight to save life and not take it, and they are very uncomfortable in pulling the plug even when they can read the writing on the wall.

I remember the time last year when my grand mother all of 105 years lay critically ill in a hospital in Delhi. She was admitted to the hospital with a gastrointestinal infection, which had seriously dehydrated her. As a consequence of this her electrolyte balance had gone askew and this had impacted her kidneys, which had shut down. The doctors treating her were former colleagues and friends. They tried their level best to save her, managed to get her infection under control with antibiotics, managed to get her electrolytes balance back to normal and put her through many dialysis hoping that her kidneys will restart. We watched helplessly as our grandmother put up a brave fight. She virtually disappeared under the tubes, which seemed to be sticking out from everywhere. We reached a stage, where she and we knew that the end was near. Yet we wanted a miracle to happen, we kept telling the doctors to keep trying and not give up. None of us including our doctors wanted to take the decision, which was but inevitable. Eventually we did realize the futility of our efforts, we asked the doctors to allow us to take her home, where two days later she passed away peacefully.

Now is this euthanasia? Isn’t it how all of us would want to bow out from the world with dignity, in our own beds surrounded by people we love. Won’t we want our doctors to be wise and courageous enough to accept defeat and let us go, rather than needlessly keep fighting against the inevitable. I believe that the canons of medicine do allow doctors to stop treating, when nothing more can be done. Moreover, I would like to believe that the doctors must also help by making once passage as painless as possible and all this should happen with the patient’s or their immediate family’s active and informed consent.

Why shouldn’t we trust our doctors in death as much as we trust them in life? The law must allow doctors to take this final call keeping the best interest of the patient in mind. The law must define a reasonable protocol to be followed for passive and active euthanasia and let the medical folks do their duty as best as they can.

Marketing A Laparoscopic Surgery Program

Marketing a surgery program is fraught with risks. Barring surgeons, I am yet to meet someone who looks forward to a surgery. Most people try to avoid surgery as much as they can. They will come up with all kinds of excuses including astrological considerations, the weather not being right (it is either too hot or cold or raining) or waiting for a son or a daughter who lives abroad to arrive before they can go under the knife.

The fear of surgery is universal and whatever the surgeon might say (I have done it a thousand times, I do it every day etc.), the fear of surgery just does not dissipate. Whatever the surgeon may say, the fact remains that patients undergo surgery only when they do not have any other medical recourse. Given a choice between a surgery and any other non-invasive medical procedure a patient will always choose the latter.

Now, marketing a surgical program, which no one wants (or at best agrees to only as a last resort) is to say the least, challenging. With the advancement of technology a whole lot of surgeries can be done using a laparoscopic techniques. This is indeed a great boon for patients, who as I mentioned earlier are extremely reluctant to go under the knife and by corollary once subjected to surgery are very keen to return home to normal life. Laparoscopic surgery, which is also at times called Minimally Invasive Surgery allows surgeons to operate with just a few holes through, which they insert a camera and other equipment necessary for the surgery. Minimally Invasive Surgery is far superior to conventional open surgery as it is a lot safer, allows faster recovery, has less chances of infection and usually involves minimal loss of blood.

To effectively market a laparoscopic surgical program it is essential that the patient understands its huge benefits. Since, patients after a surgery want to return home faster, I would suggest that we brand the laparoscopic surgery program as ‘Short Stay Surgery’ program. This is easily understood by all and has a certain appeal for patients-instead of focusing on surgery, they would rather look forward to a short hospital stay and a quick return to home. Fortunately, many surgical procedures done laparoscopically allows patients to return home with in 24 hours, which is just great.

Once the program is branded as ‘Short Stay Surgery’ program the other benefits of the program must be highlighted all flowing into the core benefit of a short stay in the hospital. The surgeons in their spiel should highlight this aspect of surgery as much as they can. This is not to say that they should gloss over the risk factors of the surgical procedure, it is just that the prospect of a possible shorter stay in the hospital will make the patient feel a lot better.

The advertising communication should highlight facts such as faster recovery, minimal scarring, less pain, low blood loss and less chances of infection as clear advantages of laparoscopic surgery. It should then connect this up with the core benefit of a shorter stay in the hospital. I believe such an approach can go a long way in popularising minimally invasive surgery and patients will actively seek a surgical intervention at the right time rather than wait till there is an emergency and waiting may no longer be possible.

The tonality of messaging is just as critical as the message itself. One has to be very careful in not sounding over enthusiastic and too keen in the advertising. One must remember that inspite of all the advantages of laparoscopic surgery, it still is surgery. From a patient’s perspective this involves a detour to the hospital and the attendant risks can not be just wished away. The communication must be couched in a language, which is solicitous, understanding and educative. It should connect with the patient and help him understand that the short stay surgery program lessens risks significantly and allows him to get over the medical crisis faster.

The use of media of course depends on the budget available with the hospital. Print, Television, Outdoors, Radio, digital and BTL can all be effectively used to create an impactful campaign. The choice of media can amplify the messaging and help more people connect with the hospital.

And choose laparoscopic surgery in time rather than wait till they are left with no choice.

Thoughts on Cadaver Organ Donations in India

Organ donation in India is still in its infancy. Everyone from the Union Health Minister Ghulam Nabi Azad to doctors working in both private and public sector hospitals concur on the need for more donations and advocate the creation of Organ Banks, greater public awareness about the noble cause of organ donations as well as on the urgent need of passing laws and developing transparent, hassle-free mechanisms, which allow swift organ retrieval, banking and transplantation.

I believe that the entire Transplant Program suffers from at least three severe malaise. These are lack of governmental regulation, poor infrastructure for quick retrieval and transplantation and total public apathy.

Apparently a comprehensive ’Transplantation of Human Organs Act’ is being considered by the Indian Parliament. The act once cleared by the parliament will hopefully lead to a far better utilization of the donated organs and create a network of Organ Banks, which would be able to freely exchange information about the availability of an organ, its swift retrieval, its likely recipient and the hospital, where the procedure might be done. While one can hardly fault the government on its intent, the execution of the program will determine its success.

The government must establish clear guidelines on brain death, when can organs be harvested, which hospitals (both privately owned as well government hospitals) are notified for organ harvesting as well as transplants, who all can donate an organ and what would be the process for locating the recipient once brain death has been established.

I would recommend that the government should establish an autonomous body, comprising of eminent doctors, organ transplant surgeons, lawyers of repute and other medical professionals who can come together to formulate guidelines on organ donations and transplants, establish mechanisms for quick retrieval and harvesting of organs from a brain dead donor and most importantly locate a recipient awaiting a transplant.

A national registry of all those who are in need of organ transplant should be established forthwith. It should list all individuals who need a transplant and should have their detailed medical records available on the touch of a button. The registry should also list organ banks and the hospitals who have the infrastructure and the capability to carry out transplants. These hospitals must have nodal officers/doctors, who can act quickly once a brain death has been established. These officials should access the medical records of those listed as needing an organ on the national registry, check out if they are suitable candidates for receiving an organ, establish the logistics of getting the organ and the recipient together at a hospital where a transplant can be carried out and than start the process of getting the patient and the organ to the hospital.

While, this may sound simplistic, this would require immense coordination and effort. This calls for a dedicated body, state of the art IT infrastructure, logistical support in safely transporting the organ, getting the recipient to the hospital at a moment’s notice and gearing up the hospital for a fairly complicated surgery at a very short notice. The government must take the lead in setting up this mechanism and ensure that it is fast, efficient and incorruptible. Most importantly the workings of this body, should be completely transparent. I fully understand that often this body will have to take decisions regarding who gets an organ and perhaps a new lease of life and who doesn’t. These will always be hard decisions, involving questions of life and death and must be taken with utmost care, without any prejudice and in a completely transparent manner. Thus, we must have people with a track record of great efficiency and of unimpeachable integrity running this institution.

Last but not the least, it is imperative that the government create awareness about organ donations. Cadaver donations in our country are minuscule. The trauma of the untimely and unexpected death of a loved one itself usually numbs the minds of those, who have take decisions related to donations. To make matters worse, many people still believe in reincarnations and can never imagine donating organs lest it impacts life in the other realm. The government must fight these obstacles resolutely, it should educate people about the benefits of organ donations and maybe reward folks who decide in favour of donations.

Donating organs of a loved one so that people, mostly strangers, get a new life is undoubtedly the most noble of gestures. It requires courage, conviction and immense generosity. The government must ensure that once someone takes a decision like this, the organ reaches the right recipients and many lives are saved. This should happen all the time, seamlessly and without fail.