Medical care at End of Life
By Dr S.K. Jindal
Death is a logical and inevitable conclusion of life. The dignity of death, therefore, is as important as that of life. But for the fortunate few, who die in time without much suffering, most people face a prolonged death either from the debility of old age or of an incurable and progressive illness. There is also a significant contribution to this prolongation made by modern technology. "Technology has made us gods long before we are worthy of being men."

The future is here-II
New era in organ transplantation-II
"What about Lyons?" asked Hakim. "You know Dubernard well and he's got the political clout to get something like this through." Dubernard was head of transplantation and urology at the city's Edouard Herriot Hospital and had carried out France's first pancreas transplant in 1976.

Medical care at End of Life
By Dr S.K. Jindal

Death is a logical and inevitable conclusion of life. The dignity of death, therefore, is as important as that of life. But for the fortunate few, who die in time without much suffering, most people face a prolonged death either from the debility of old age or of an incurable and progressive illness. There is also a significant contribution to this prolongation made by modern technology. "Technology has made us gods long before we are worthy of being men."

There is a rejuvenated interest in modern medicine in End-of-Life issues including the care of the terminally ill and dying patients. This is an area which requires the involvement of people from different spheres beyond doctors and other medical personnel. Technological advances of the last few decades have made us believe that death is an unnatural event and that life can be prolonged at will. This, unfortunately, has resulted to a level in the adoption of treatments and other life-supporting measures which are often antagonistic to the very dignity of life.

Such are the complexities, and perhaps compulsions, of modern medical care that a terminally ill individual suffering from an incurable illness lies isolated in a hospital or a nursing home at a time when the presence of others is needed. In different intensive care units, he or she is most likely to be tied with several wires of multiple life-supporting systems and with catheters in and out of different parts of the body. He or she is often sedated and is unable to communicate with the near and dear ones around him or her.

On the other hand, a dying patient in a general ward is more often shunned. Having little to offer by way of a cure or consolation, one tends to avoid facing the person. Factually speaking, even relatives, nurses and doctors are afraid of talking to the dying lest they hurt the sentiments and traumatise the patient.

There is also a scenario when a very sick individual is surrounded by a crowd of anxious and sometimes curious family members and friends, interfering with both peace and privacy. This is a scene which is better avoided, howsoever well meaning the attendants and visitors may be. A patient is ordinarily inhibited in expressing his agony and wishes in the presence of too many people.

In most situations as above, it is the patient who becomes the victim, even though inadvertently. Whether it is isolation in the intensive care unit or the protection and over indulgence of care in the general ward, a patient is quite bewildered and wary of all that is happening. Everyone, from a relative or a friend to the doctor incharge is perhaps too careful and cautious to let one express one's feelings or desires. Some patients have simple things to talk about with regard to the fulfilment of their wishes. It helps to listen rather than reassure all the time.

I can never forget an old man with advanced lung cancer who had hesitatingly confided in me that his family was not ready to let him have sweets, which he enjoyed all through his life, lest his diabetes should get uncontrollable. He felt worse than even a criminal condemned by law to die whose death wish is always honoured. I did help him in my own way. Another person had wanted the water of the Ganga to be put in his mouth before death. His family was suitably informed of his desire.

Unlike in scenes in movies, people on death-beds rarely cause highly philosophical or emotional dialogues. They are so overtaken by the misery and agony of the illness that the thought process rarely extends too far. Moreover, there is almost always a varying degree of the clouding of consciousness. This is not to say that some patients may not continue to think and express as intelligently as ever till the very end. But their numbers are few and diseases less aggressive.

Relief from pain and suffering is an important issue at the End of Life. Drugs may help but only to a limited extent. Unfortunately, most drugs required for this purpose are not necessarily safe. Sedatives, for example, administered to produce some sleep or give relief from restlessness, breathlessness and extreme anxiety may depress one's respiration and other brain functions. The patient may lapse into a coma and may never remit. Such are the risks which are unavoidable. It seems more logical to take risky options for palliation rather than let a person continue to suffer in agony. Different people, however, have different opinions on this issue.

Obviously, there are different socio-religious, legal and personal angles to the End of Life care. Excessive economic burden is a very important issue which concerns most patients and their families. This is especially so when resources are limited and hopes are dwindling. Money is required to be spent as never before. For some, it is like buying a miracle. For others, it is the repayment of a debt which they owe in kind to the dying — for love, affection or duty. I have always found people complaining of this burden. But there are very few who opt to discontinue. One generally thinks that someone else shall decide. Who else can decide? It is a very hard decision to make.

Professor Jindal heads the Department of Pulmonary Medicine at the PGI, Chandigarh.

The Sri Lankan connection
A tale of exemplary medical gallantry
By Dr M.L. Kataria

Sri Lanka, the LTTE and India's assistance in some form are once again making the headlines ever since the Sri Lankan troops have suffered a series of debacles in Jaffna. The old IPKF wounds, which still have not healed into dense scars, have again started bleeding. This is agonisingly obvious from the pathetic outbursts of many of the bereaved and wailing next of kin of nearly two thousand martyrs. They cry. Their dear ones were pushed in haste and hurry and sacrificed for "no cause".

In this atmosphere, surcharged with sympathy and emotion, the forgotten tragic story of an unsung hero of the IPKF, naturally comes to one's mind.

In 1985, Major Ashwani Kumar Kanva, a handsome and brilliant doctor and sportsman, with several honours during his academic career, volunteered for a challenging medical charge of the Border Roads Organisation, engaged in the extremely hazardous task of opening up new communication lines at the Himalayan heights in Jammu and Kashmir. The terrain and the stress and strain of service are notorious for high-altitude casualties owing to lung oedema, frost bite, gangrene, loss of limbs, pneumonia, snow blindness and other ailments. Because of his professional skill and dexterity, and diligent and tireless preventive, promotive or curative measures, there was not a single casualty during his two-year tenure in the organisation. For this exceptional achievement he was deservingly honoured with the Vishisht Seva Medal.

In 1987, Major Kanva, VSM, was brought down from the snow-bound mountains. He was now given the medical charge of the 93 Field Regiment, which was drafted into action in Jaffna with the IPKF. for Major Kanva it was a tragic leap from the frying pan into the fire. On the fateful day of November 3, 1987, while the regiment was engaged in a grim battle of "Op. Pawan", Major Kanva was treating the wounded soldiers at his medical aid post. Through his binoculars, far away from his post, he saw several soldiers of his regiment bleeding profusely. Totally unconcerned about his life and safety, this gallant soldier-doctor rushed out of his protected medical aid post, with whatever resuscitation equipment he could carry along with his assistants, to save the lives of the soldiers bleeding in the battle field. He did save them. But, alas! A ruthless, indiscriminate LTTE sniper, perched on a tall palm tree in a grove, aimed at him and gunned him down. Are irregular rebel armed forces not required to observe the Geneva Convention, which grants immunity to medical relief workers in the battle zone?

Major Kanva saved his comrades but himself bled to death. The doctor died untreated and unsung....

The medical history of the Second World War and the available records of the subsequent wars thrust on us by Pakistan and China do record doctors wounded or killed in action and suitably honoured.

Nevertheless, there is no parallel to Major Kanva, who totally unconcerned about his own life, ran out of his aid post in the midst of fire to professionally rescue his comrades and was sniped to death. This is a unique example of cool gallantry mingled with hot-blooded professional diligence.

Some persons have been honoured posthumously by the State even with the highest award. It is outrageous that this proven daring professional hero from the mountains, who became a martyr in the plains of Jaffna to save the lives of comrades at the cost of his own life, remains unsung, in spite of being an example of being the rarest professional gallantry in any war.

It adds to our national pride to respect the fallen and the brave. Let us salute Major Ashwani Kumar Kanva, VSM, the unsung hero of the IPKF, and make ourselves proud by showing our sense of gratitude.

Dr (Brig) M.L. Kataria is an honorary socio-medical relief worker and a legendary healer of the hapless in North India's slums.

The future is here-II
New era in organ transplantation-II

"What about Lyons?" asked Hakim. "You know Dubernard well and he's got the political clout to get something like this through." Dubernard was head of transplantation and urology at the city's Edouard Herriot Hospital and had carried out France's first pancreas transplant in 1976.

Owen and Dubernard go back a long way. Twenty years earlier, when Owen was travelling around the world preaching the gospel of microsurgery, Dubernard had invited him to Lyons to demonstrate at medical student workshops. "Remember that time with the testicles?" Owen would often ask him. How could Dubernard forget? He had been at the airport waiting for Owen when there was a hold-up at customs. "Have you got anything to declare, and what is that terrible smell? "the officer had asked Owen. "Seventy-eight testicles. Two are mine and the rest are in this cool box." He had brought the testicles so that the med students could practise microsurgery, but a flight delay meant that they had not arrived in pristine condition.

Dubernard was able to get Owen out of a tight spot.

Today, he is not only one of France's top surgeons, but also a prominent local politician: deputy mayor and a member of the ruling Gaullist party. By the time Owen came to him with his plan, he had his own hospital department.

Some people might object afterwards, he said, but by then it would be too late. In France, the cartoon character Dennis the Menace is called Max; it is also Dubernard's nickname.

Owen quietly began assembling a skilled international team; transplant, orthopaedic and hand surgeons, all experts in microsurgery; experienced anaesthetists, a psychiatrist and a psychoanalyst specialising in "body-image disturbances". Across the Atlantic, they were blissfully unaware of these preparations but the desire for a breakthrough was just as strong.

Louisville is not a particularly high-rise city by American standards; there are a few skyscraper banks, a giant baseball bat reaching into the air, marking where the Louisville Slugger, Joe DiMaggio's favourite, is still turned by hand, and then there is "the Jewish", a handful of buildings overlooking Muhammad Ali Boulevard that forms one of the country's most advanced hospitals.

To be continued