Suresh and I [KS] were called the Siamese twins. We went to the same school and college. We branched off later—I became a doctor and Suresh an engineer-but we kept in touch. When he told me of his daughter’s marriage, I was overjoyed, but then my son’s college entrance exam was in Mumbai on the same day. Suresh instantly forgave me even while warning, ‘Come home as soon as you return; you are always late… ‘

The marriage went off smoothly and Suresh was sitting with his brother discussing the day’s events when he suddenly collapsed. By the time he was shifted to a hospital, Suresh had suffered from brain anoxia for 15 minutes. He arrived in the hospital without a pulse and respiratory effort. The doctors knew that they were treating a dead patient but, out of formality, they intubated Suresh, resuscitated him and admitted him to the ICU. The relatives gave them my mobile number and I was phoned and told to break the news. I rushed back from Mumbai and went directly to the ICU.

Among the most difficult tasks that a doctor faces is that of telling someone that their loved one is dead. That medical science is not all that it is made out to be, that in some cases doctors are helpless. This becomes doubly difficult if the dead person happens to be one’s dearest friend.

Worse still, there was no apparent explanation for this tragedy. There was no embolus in Suresh’s airway. His CAT scan did not show any infarct or clot. His ECG was perfectly normal. In fact, except for absent neurological reflexes, there were no positive findings.

When I stepped out of the ICU everyone looked up with hope, despite my serious expression. Suresh’s wife came rushing to me and said, ‘Kishore bhaiyya, thank God you have come.’ Suresh’s brother whispered, ‘Kishore bhaiyya, if you want, we can transfer Suresh to your hospital. We are so relieved that you have come. We were so confused until now.’ How could I tell these trusting people the truth? I took Suresh’s brother to one side, looked at him with brimming eyes and said, ‘Look, there is hardly any hope for Suresh. His brain did not receive any oxygen for a long time. His brain is dead.’

‘Kishore bhaiyya, I just saw his chest moving up and down. He is breathing. How can he be dead?’

‘What you see is the machine pumping air in and out of his chest.’

His face became confused. I was supposed to have come and waved a magic wand. He turned away from me.

Bhabhi asked, ‘Kishore bhaiyya, there is still hope, no?’

An outright denial was not humanly possible. I dumbly nodded, ‘Yes, there is a little hope.’

She did not hear the word ‘little’, or she didn’t want to hear it. Her tense face broke into a crumpled smile.

The newly-wed daughter came up to me and chided me, ‘Kishore uncle, this happened because you were not here.’

I did not sleep that night. Each relative would corner and question me. I tried to be factual and harsh. Nothing worked.

The next day brought with it a plethora of unknown relatives. A gentleman from Dhulia asked, ‘Where is the doctor? They are not doing anything for my dear nephew.’ I told him that I was a doctor, though I was in the hospital more as a friend than a doctor. I told him that Suresh had undergone a prolonged period of brain suffocation. The doctors had tried their best but nothing could be done.

‘Don’t teach me anything!’ the uncle said. ‘Doctors prolong treatment to extract money.’ He narrated the story of another nephew who was in the ICU for a month until a general practitioner solved the case. I tried to explain that Suresh’s case was different. Other relatives joined in with stories of miraculous cures and I found myself fighting a losing battle. It was best to avoid confrontation and nod quietly.

Suresh’s brother was sitting in a corner with his head in his hands. I told him, ‘Look, it is time that we accept the fact that Suresh will never come back. Let us donate his organs to someone who really needs them. At least his eyes. Let Suresh die a dignified and helpful death. I am sure he would have approved of it himself.’

He looked at me aghast and burst into tears. I tried my best to console him. After some time he said, ‘I have heard of a doctor in Chennai who performs miracles with such cases. I am going to get that doctor.’

If I dissuaded him, I would become an enemy for life. If I agreed, I would be responsible for his failure. I merely nodded and said, ‘It’s your money.’

‘Don’t talk about money!’ he shouted. ‘Are a few metal pieces more valuable than my brother’s life?’

I had no arguments against his statements. The next day I saw that someone had put a vermilion mark on Suresh’s forehead. The number of relatives in the waiting room had doubled. Lemons and chillies were strung here and there. Bhabhi said, ‘He is improving, I heard him groan.’

I quickly changed the topic. ‘What are these lemons and chillies doing here?’

‘That is what helped. Our uncle from Dhulia brought Baba Tribhuvan who has promised that Suresh will walk in 15 days.’

I asked with a sinking heart, ‘How much did Babaji charge?’

‘Babaji never charges a paisa. Uncle told us to give him some dakshina. He will donate it at Babaji’s ashram.’

Suresh’s brother pulled me to one side and said, ‘Kishore, please do something. I heard that there is vast knowledge on the internet. Ask your friends. There must be some way to get Suresh up.’ I knew nothing could bring Suresh back, but I searched the internet for hours for a miraculous cure. I wrote to my alumni group. Everyone told me the same thing. There was no hope. The circus of charlatans continued for four more days. A week after Suresh was admitted to the ICU it started dawning on everyone that may be what the doctors had been saying all along was right.

Some relatives were aloof as if I were somehow responsible for Suresh’s plight. Bhabhi refused to meet my eyes. She had come to know that I had advised organ donation and could not believe that I could be so cruel.

Suresh’s brother came to me and said, ‘We have decided to stop all the life support. It has become unbearable for all of us.’ I patted his shoulder and held him.

The time for disconnecting the ventilator came. All the relatives were weeping. I stood next to the body of my friend of many years. The machine was switched off.

Through the funeral journey, I pondered over my failures. I had failed as a doctor. I could not revive my friend. I had failed as a friend to protect his relatives from so-called well-wishers. I had failed as a human being to convince the relatives to at least donate his organs for the benefit of humanity.

Response 1: Not a personal failure

Most doctors have faced this situation and are familiar with the writer’s feelings of helplessness, pain and anguish.

We doctors take ourselves too seriously as life-givers. A patient’s death is viewed as a personal failure and, when the patient is a close relative or a friend, it is difficult to resolve the mix of emotion and abstract clinical response. We often forget that our prime aim is to function as healers and discharge our responsibilities honestly and diligently. Beyond this, the results are decided by another Supreme Power.

In this case, Suresh arrived at the hospital without a palpable pulse and respiratory effort and was therefore clinically dead. He was electively put on a ventilator while waiting for Dr Shah’s arrival.

An EEG examination should have been requested, as the family would more easily accept a documented brain death as compared to verbal explanations. I find that a CT scan was done but an EEG was not asked for. It is also my feeling that the decision-making should be done strictly by the treating doctor/s after detailed communication with the family. The role of a doctor friend or a doctor relative should be limited to providing emotional and logistic support. This would ensure that interventions and decisions are made on the basis of sound and unbiased judgement, so necessary in good clinical practice. This would also prevent the doctor friend from feeling guilty. Similarly, organ donation is a sensitive topic and should only be broached by a professional organ donation team. Finally, doctors need to learn early, preferably during their training, that they are not God in a white coat.

Ratna Magotra

Response 2: Denial, collusion and inappropriate hope

The story about Kishore, a doctor, and his friend Suresh, is a classic example of what happens when there is improper communication between health professionals and the individuals they care for.

The entire problem began when the doctors admitted Suresh in the ICU even though he was brain dead. We tend to be overwhelmed by the distress and anxiety of the family and take the easier way out—admit the patient rather than counsel the family.

An important thread that runs through the story is that of hope. The subject of hope invokes emotional and sometimes violent responses from people! ‘Who are we to kill someone’s hope?’ or ‘How can we play God and say that there is no hope?’ I liken hope to a drug. It has its uses. It must be administered in appropriate doses, at the appropriate time. It has excellent therapeutic value but also has dangerous side-effects! Hope is good, but it must be appropriate. Right through the story, the avoidable agony was created by holding on to inappropriate hope. While it is perfectly natural for the family members to do so, the health professional must use all his skills to steer the family safely at times of crises.

I understand the agony of Kishore, who had two roles to play—that of a doctor and a dear friend. When there is conflict between these two, it is best that one withdraws from one of the roles—the choice is left to the individual’s comfort. Health professionals forget that they are also human and have normal feelings. One of the difficulties in communicating bad news is that we feel personally ‘responsible’ or ‘guilty’ for what has happened. We are loathe to ‘let the patient down’.

Another major issue is denial. It is how one simplifies the complexities of life. It reinterprets a part of or the whole situation that is painful and looks at it as one wishes it to be. Denial is an excellent coping mechanism, used effectively by many. As you read the story, you find denial everywhere. In a situation like this, the health professional must use all his skills to break denial. It is important to know when denial needs to be broken—when it causes refusal to take treatment, prolongs expensive ineffective treatment or makes the patient commit acts that would pose grave danger or financial ruin to himself and his family. Kishore could have challenged the denial by saying something such as, ‘How do you say that he is OK or improving?’ or, after presenting medical facts gently, say, ‘I know it is difficult for you, but is it not obvious that our hope is inappropriate?’ and ‘Keeping him on the ventilator is only prolonging Suresh’s misery and serves to make us feel less guilty.’

Relatives are well-meaning but create problems without intending to do so. One must not take a confrontational attitude or be unduly upset. The basis of their acts is love and concern for the patient. They are also in denial—unwilling to accept the truth.

Using faith healers, alternate treatments, etc. is natural. It is born out of the inbuilt desire to live on. There is no harm in allowing the family to pursue all possible channels, as long as you, as a health professional, are not responsible for leading them up the wrong path because of your unwillingness to reveal the truth.

Hiding the truth from loved ones is referred to as collusion. It is an act of love and must not be trivialised. It needs to be handled with sensitivity, as the emotional consequences of the pretence or charade are devastating.

Health professionals must learn to identify key people of the family and restrict their communication with these individuals to prevent unnecessary confusion.

And finally, Kishore’s guilt that he ‘failed as a doctor because he could not revive his friend’ is understandable, but it was not possible for him, under the circumstances. Yes, he failed by not addressing the other important issues—that of denial, collusion and inappropriate hope.

S N Simha