Critical question

In medical emergencies, can doctors keep patients’ families in the dark about treatment procedures?

After the sudden death of politician E Ahamed, his daughter said she was not allowed to see her father or told how he was doing while he was in intensive care.

Dr Fouziya Shersad struggled to control her grief while describing her ordeal at the Dr Ram Manohar Lohia Hospital in New Delhi last week where her father, veteran politician E Ahamed had been taken after suffering a massive heart attack. Ahamed had collapsed on the floor of Parliament on January 31 at 11.30 am when President Pranab Mukherjee was addressing its joint session and was immediately taken to the hospital and was put on life support system at the trauma care Intensive Care Unit.

Dr Shersad, and her husband Babu Shersad are both doctors. They alleged that the way the family of the patient was treated goes against medical ethics.

“My husband Babu Shersad who is also a medical practitioner, and I reached at the hospital at 8.30 pm on January 31,” she said press conference at her home in Kannur last weekend. “However, the doctors didn’t allow us to see our father. We waited outside the trauma care ICU without knowing what was happening inside.”

Seventy eight-year-old E Ahamed was a seven-time Parliamentarian from Kerala. He had served as Minister of State for External Affairs in the Manmohan Singh-led UPA government from 2004 to 2014. He was the national president of the Indian Union Muslim League, a political party that enjoys considerable clout in Kerala, from 2008 till his death, which was announced at 2:45 am on February 1.

“The doctors used the chest compression device for more than 10 hours,” alleged Shersad, who is a faculty member of the Pathology department at Dubai Medical College. “Ideally it should be used for a maximum of 40 minutes. Overuse of the equipment might be the reason for the bloating on his face.”

As a doctor and the patient’s daughter, Shersad disagreed with the treatment provided to her father. But she was not informed about the treatment provided to her father, even after her arrival.

Dr Sanjay Nagral, a surgeon from Mumbai and publisher of the Indian Journal of Medical Ethics, said that it is unacceptable for doctors to deny relatives permission to briefly see a critically ill patient in intensive care. “Relatives have the right to see the patient. Doctors can deny access only if the patient is undergoing a surgery or a procedure.”

Nagral said doctors should inform relatives the status of the treatment and condition of the patient periodically.

“In Ahamed’s case the duty doctors should have consulted the treatment methods with his daughter and son-in-law, who are medical professionals.”

He added that doctors should remember that they are answerable to patients and not to the hospitals.

Politics over the death

Doubts about Ahamed’s medical condition were raised when the hospital authorities denied permission to his family members, political leaders and parliamentarians to visit him in the ICU.

“Soon after he was shifted to the hospital, a representative from the Prime Minister’s office had held a closed door meeting with the doctors,” said ET Mohammed Basheer, IUML national secretary and Member of Parliament. “The decision to announce his death after the Union Budget presentation was taken in the meeting.”

Other leaders have protested and called for an investigation into the hospital’s handling of the case.

The hospital, however, denied that it suppressed or delayed news of the minister’s death. “A team of experts revived him by putting him on a pacemaker, ventilator and cardiopulmonary resuscitation on arrival at the hospital,” said medical superintendent AK Gadpayle, in a statement that the hospital issued. “All possible efforts were made by the doctors. However, he succumbed at 2:15 am due to complete heart blockage, cardiogenic shock, diabetes with hypertension.”

Apart from the political ruckus, Ahamed’s death brings to light a glaring gap in medical protocols – that there is no common treatment protocol for hospitals to follow when it comes to dealing with patients families.

When Ahmed’s relatives demanded reasons for denying the entry, a doctor said they were just following the hospital protocol. “When we pressed him to show us the protocol, he said there was no written protocol document,” Shersad said.

Shared decision making

Teams of doctors in different countries have considered the question of how to interact with families of patients in intensive care and critical care. Guidelines developed by doctors in Korea, for instance, talk about shared decision-making, where “physicians work together with patients and their families to define the patient’s healthcare values, beliefs, and treatment preferences.” As per the model, the physician could recommend a treatment that she believes to be closest to the patient’s values and goals.

This principle has been accepted by Indian doctors too.

In 2012, the Indian Society of Critical Care Medicine developed an ethical framework and practical procedure to improve the quality of care of the dying in the intensive care unit. The body sought to frame the guidelines through a professional consensus process.

The guidelines recognise the need for shared decision making to free the patients’ relatives from anxiety. “Surrogates need to be well informed and free from incapacitating anxiety and depression to be able to function effectively as substitute decision-makers for the patients,” the guidelines elucidate.

Doctors are also bound to inform patients’ families immediately when a patient dies, said Dr Puneet Bedi, obstetrics and gynaecology consultant at Indraprastha Apollo Hospital in New Delhi.

“Medical ethics are universal and absolute and not subject to political affiliations,” he said. “Some doctors may go against medical ethics due to political pressure but it cannot be justified in a court of Law.”

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.

Play

SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.