Coping with death

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High-tech hospital care must include mandatory counselling by advisers, independent of the medical management. This will enable us to take rational decisions in time. If we don’t, we will end up spending most of our money on healthcare in the last years of our lives

Quite unlike the ‘developed’ world, India does not have an ageing problem. With an overwhelming number of young people, its population will remain youthful for at least two decades more. While the grey may never show, the addition of 90 million elderly in the next 20 years will increasingly make hospitalisation a longevity hazard. A couple of decades ago, 80 was considered a ripe old age. Nowadays people live into their nineties and the chances of confronting serious medical problems swell.

In recent months, I have witnessed three old men in the 80 plus age group getting hospitalised post a sudden stroke. The first stop is naturally the ICU, entailing a battery of investigations, followed by ventilators, tracheotomies, oxygen masks, feeding tubes and day and night nursing. The family does not have a clue about where this is leading, but cannot bear to see the old man go. They plead with the doctor to tell them what his chances are.

The doctor does not have an answer, but he abstains from giving false hope, while trying not to upset the stricken. He also cannot predict things, but stands to lose clients by seeming hopeless or helpless. Looking at the patient’s age and general health, he knows that the old man should survive in an unconscious state – maybe a month or two, on ICU support systems which cost a whopping Rs 10,000 to Rs 15,000 a day. He elects to tell the anxious relatives, “The old man can pull through if he shows will power. We will do our best of course. The rest is in god’s hands.” The family huddles together observing the old man breathing heavily through masks and tubes, his eyes closed to the world.

Meanwhile, distraught children (now in their forties and fifties) fly in from the US or Europe, balancing last minute tickets and hard to get leave. Thoughts of unsupervised teenage children, wrecked official commitments, and a home devoid of domestic support, loom large on the flight. Every day spent in India is an extension of that anguish, but any mention of returning meets with dismay and disapproval from resentful siblings who have tended the old man for the past 20 years. Throwing money at the problem only generates bitterness and the charge of callousness. Yet, visiting an unconscious parent in the ICU at the appointed hour, twice a day, becomes a painful and meaningless chore, followed by pointless family conclaves in crowded hospital lobbies.

Only when the costs of ICU become unmanageable, does pragmatism overcome emotion and impart courage enough to demand a step down to less intensive care. Legal and medical advice cautions that the ventilator would have to be removed and the old man may succumb on the spot. “We are prepared,” says the family in unison, confronted with soaring ICU bills and demands for instant payment. The old man remains unconscious but does not collapse. He adjusts well to his step down status, but remains near comatose and dependent on props.

But costs in the private ward too become prohibitive, eventually making yet another step-down unavoidable. “Can we remove him to a smaller hospital, doctor?” “By all means,” says the doctor, “but wherever you take him, the new hospital will insist on putting him back in the ICU and will re-run all the investigations from scratch, I warn you. All hospitals are bound to do that.” A parley with smaller hospitals confirms this statement. The new management scans through the case papers and flatly refuses to handle the patient unless he comes as a “new case”.

The last resort is to nurse the old man at home. As usual, it becomes the responsibility of the harassed spouse or the non-NRI progeny, to engage nurses, attendants and physiotherapy services that constitute the gruelling job of providing home care. The beleaguered offspring returns home to the US after spending a miserable fortnight in India, dejected, remorseful, but hugely relieved to get away. Those left to care for the old man feel forsaken at such cavalier neglect of filial responsibility. They curse the cult of self-centredness that comes from living in the new world.

The old man lingers on. Domestic management of apathetic paramedics, attendants and physiotherapists becomes a nightmare. There is little sadness when the end comes. Indeed, it comes as a relief.

Increase in life expectancy is good news but alongside the likelihood of critical conditions developing at an older age will increase. Scores of multi-specialty hospitals already vie for national accreditation and international recognition. As more Indians live to see what the French call the quatrieme age, some are fated to spend their last days and lifetime savings on dying under ISO 9001:2000 care.

It is time that high-tech hospital care includes mandatory counselling by advisers, independent of the medical management, but competent enough to give meaningful counsel. This will enable the family to understand what is going on and take rational decisions in time. Lest like America, we too end up spending ninety per cent of our lifetime expenditure on health, in the last year of life.

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