When a patient has previously expressed the desire never to go on a ventilator

Mrs SBG, a sprightly eighty year old, lived alone in south Bombay. She became short of breath over a two week period. She had chronic obstructive pulmonary disease which was related with inhalers. Her blood gases showed severe hypoxia as well as hypercapnia. Though her sensorium was mildly lethargic, she had appropriate judgement. She had bilateral crackles in the lungs and pitting edema up to the knees.

Two years prior to this illness she had developed respiratory insufficiency requiring a ventilator while recovering from surgery for subacute bowel obstruction. That whole episode had been so traumatic to her that she had repeatedly declared never to go on a ventilator again. Her daughter and son in- law, both doctors, were well aware of her wishes.

The cause of the current worsening of her respiratory condition was presumed to be a combination of right sided heart failure and possible lung infection.

What should her relatives do at this point? What would the readers do? Should they honor her previously expressed wishes and let her deteriorate slowly at home providing only comfort and support? Should they ask her again about her wishes regarding the ventilator in case she had changed her mind in face of obvious respiratory distress? Should they overrule her previous wishes and take her to the hospital assuming that this current problem was an acute condition which would resolve with vigorous treatment and return her to her previous feisty self?

When the options are expensive and may be futile

Our gardener wanted to discuss his wife’s illness. She was recently diagnosed to have germ cell cancer of the ovary at the local public hospital. Chemotherapy was advised, the cost of which would run into several thousand rupees. He wanted to know what he should do.

He had two small children. He worked in a factory and had taken on additional employment as gardener for several people like us and made the rounds of his customers on a motorcycle he had recently purchased so that he could reach more customers in the time available in the evenings. He told us that he did not much in the way of savings but thought that he could raise some funds by selling off his motorcycle. He had discussed his financial situation with the social worker in the public hospital who told him that he would be eligible for some financial relief but would still be responsible for the major portion of the cost.

Should we give him all the information that we could find out about this disease? Should we let him then make up his own mind? Should we explain that the prognosis for this disease is pretty poor? What if he misunderstood our description of statistical odds and decided on no treatment at all? Or what if he bankrupted his and his children’s future chasing the possibility of a cure?

How does one convey the uncertainty in medical treatment and outcome? Or should we discuss the options ourselves and tell him to follow a course of action that is right in our opinion?

What would the readers do?

The dilemma of the health care worker

What should health care workers do when they are asked to participate in a procedure that they oppose morally? Is there room for ‘cooperation with disagreement’?

Taking the example of abortion, to what extent does the individual health worker have a right to object to participate in an abortion? At what point? What is the appropriate response of a gynaecologist who opposes abortion but is asked to perform one? What if the woman has a tubal pregnancy and emergency surgery is necessary to save the mother’s life? Can the anaesthetist also refuse to participate? The operating room nurse? Is it acceptable for the orderly to refuse to wheel the patient into the operating theatre? And the medical student on rotation who is asked to take a medical history before the abortion? The clerk who must admit the patient? What if this is the only health service in the vicinity?