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.”

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