ISA ONLINE MASTER CLASS:CHANGING GEARS....END OF LIFE CARE

[00:00:03]Okay. So, we can start. The live streaming is on.

[00:00:15]>> Good evening.

[00:00:19]>> Okay.

[00:00:21]>> Uh good evening everyone. Uh I welcome you all to this edition of PG online classes and I hand over the mic now to Dr. Gori. Dr. Gori is an accomplished anesthetist from she's a director and proprietor of Aurora Hospitals at Nagpur. She's a past president of ISA Nagpur and has been actively involved in all the ISA activities. Over to you ma'am for today's proceedings.

[00:00:45]>> Thank you Dr. Par. A very good evening to all of you. Respected uh president ISA national Dr. Navin Maludra sir, honorary secretary ISA national Dr. Vita sir. Uh respected Dr. call sir uh DC national ISA national DC VC uh Dr. Indrani Sumar Madam um DC Dr. uh DC National Dr. Parindal and uh all respected seniors, teachers, friends and dear PG students.

[00:01:20]Uh I welcome you all to today's ISA national PG online class and the topic is changing gears end of life care which means that it's a transition from the aggressive uh curative approach to a paliative comfort care that mainly includes uh pain man quality of life and ensuring dignity at the end end stage of life and this also involves at times advanced directives like uh documents like DNR or living well before we begin uh we will seek blessings from the almighty so can we play the Sarasati Dr. Mom, Jer.

[00:02:34][singing] [chanting] foreign.

[00:02:45][music and singing] [music] [singing] [music] [singing and music] Fore! Foreign! Foreign!

[00:03:11][music] [music] >> [singing] >> Thank you. On behalf of ISA National, I would like to welcome our esteemed speaker for today's topic, Dr. Abil Dams.

[00:03:37]May I now request our honorable president, Dr. Navin Mahotra, to please say a few words.

[00:03:45]>> Uh, thank you Dr. Gori uh it's pleasure uh to have you uh at this platform and it's always a pleasure to uh interact with you.

[00:03:55]>> Thank you.

[00:03:57]>> Uh when I met Dr. Dr. Abijit Dum a week ago uh in Jamshedpur.

[00:04:07]I was really impressed by the work he has been doing for the decades and decades for end of care end of life care and the one thing which he asked okay how many of us has planned for our death how much investment we have done in death and the answer was zero and nil so I requested Please share your thoughts, experience with the rest of the country and uh so that everybody can be become more wiser by his experience and thoughts. So today's topic is is clinical but at the other side it's emotional also spiritual also and uh I'm very sure all of you will be enriched by the experience which he has. So thank you Dr. Dang for uh joining us and uh as a president of ISA National I convey my greetings to all the anesthesia technologists uh on today's 10th National Anesthesia OT an uh national OT technologist day and as I've said in my message you are a strong support and pillar for us a clinically sound technologist is a very very uh comfortable to the anesthesiologist but at the same time please do not administer anesthesia yourself. It is legally not allowed and it is not safe to do it. So it has to be done by qualified anesthesiologist only.

[00:06:06]So uh thank you very much. I look forward to an interesting session by Dr. Tabijit Dam. Thank you.

[00:06:13]>> Thank you Navin. May I now invite our honorary secretary Dr. Raki to say a few words.

[00:06:23]>> Good evening everyone. I welcome you all to this is online master class on changing gears end of life year. So first of all I would like to congratulate you all for a very good thing that happened today. Vicram one was launched successfully into the orbit earth's orbit. So this is one of the private vehicles which was launched in India. So I congratulate each and every Indian to be proud of it.

[00:06:54][clears throat] Now we come to see that uh Dr. Dam has you know he's you know he's a pioneer in explaining how we have to go for end of life care though medicine has evolved so much that they have pushed the boundaries of life to another extent but to add life to these ears when you need most care is something you know very empathetic. It touches your heart. Once you listen to Dr. Abijit, you'll come to know how compassionate and empathetic the topic is. And uh without much delay, I would like uh Dr. Abijit to invite for this beautiful lecture over to Dr. Gori.

[00:07:52]>> May I now invite Dr. Thank you glory and also yes ma'am I request you to >> yeah thank you so much Gowi um >> thank you >> actually this lecture will be an eyeopener to all of us you know to have a comfortable able and meaningful life in the evening in the evening of our lives and it is my pleasure to introduce Dr. Abijit Dham.

[00:08:34]Dr. Abijit Dam is the founder ex-president national association of paliotative care for Aayush and Integrative Medicine.

[00:08:45]He's also the medical director Koshish the hospice in rural Jarant.

[00:08:52]He's ex- secretary of Indian association of paliative care, founder president international death da foundation and he did his basic uh MBBS from RGAR medical college Kolkata MD in the year 1995 from as New Delhi and he's a certified paliative medicine uh in the year 2006.

[00:09:21]He is also a fellow of international pain management in the year 2008. He has done MSE in paliative medicine in 2013 certification in advanced vanta in the year 2012. He's also a fellow in successful aging from Stanford University in the year 2013 contemplative and end of life course from USA again in the year 2013.

[00:09:50]He's also a PhD in pariff psychology and national faculty in Indian association of paliotative care. Thank you very much sir for being part of our master class.

[00:10:03]Over to you sir.

[00:10:07]>> Thank you very much and uh would I begin with your permission?

[00:10:13]>> Yes sir.

[00:10:24]Well, uh, the title of my presentation is changing gears.

[00:10:30]Now, most of you would be familiar driving cars and when you're driving on a highway, you usually drive on you drive on high gears like fifth gear or sixth gear, that sort of thing. But when you drive through the small alleys or you know the gullies of crowded cities, you can't drive on high gears. You have to change your gears. You have to shift your gears. You have to lower your gears because driving at high gears would not be possible when you are you know navigating your way through narrow lanes.

[00:11:07]End of life care is something like that.

[00:11:11]All those big interventions and uh you know uh those uh so many medications and interventions which are appropriate when there is a possible of survival where there is a possible of reversal of the pathology then it is appropriate. But when you know that this particular person is not going to make it and most of us almost all of us know at some point of time and that is what we uh uh we we call uh you know uh that asking yourself that magic question asking yourself that question that it is also called the surprise question. You ask yourself, would you really be surprised if this particular person or patient would survive for another week or a month, maybe a year at the maximum and if the answer is no, that you would actually not be surprised if he dies within a month, then you need to change gears.

[00:12:19]You need to change the way you are treating the patient because you are no longer treating them. you would now be helping the patient towards this onward journey. Helping in which sense I'm not saying that you would actually you know kill the patient but what you can do is to provide comfort care so that the patient can spend his last days of life in peace. He can spend it without any painful symptoms. He can spend it preserving his dignity and that is so very important.

[00:13:04]Our medical system I believe is somewhat flawed. Uh this is a photograph uh which was uh taken when I had gone to Poland for my training in paliative care.

[00:13:20]uh during my MBBS days I remember when we used to do the medicine rounds uh or the surgical rounds our professors told us that you make sure that you don't you know sit on the patient's bed that is that is not simply not done but here you can see this is professor Uchek uh this elderly gentleman and he actually taught me the art of sitting on the patient's bed by it doesn't mean that just sitting on the patient's bed. It means that how to communicate with the patient so that the patient feels that you are actually communicating.

[00:14:06]Most of the time we don't communicate.

[00:14:08]We just speak or we just lecture.

[00:14:11]Lecture is a oneway thing but it's a oneway traffic. To communicate you have to get into the same frequency. You have to resonate. When the frequencies match you resonate, you create music with the patient.

[00:14:28]So, professor had taught me that art.

[00:14:32]So, it required a lot of unlearning and then relearning.

[00:14:39]And over the years, I began to love it.

[00:14:46]Dying is the most important event after birth. It is not just a physical phenomenon.

[00:14:55]It has social, cultural and spiritual ramifications as well. And these dimensions are hardly addressed.

[00:15:03]You see, so you have so many patients dying in your ICU or in your practice, whichever practice be it, you have patients dying.

[00:15:13]But when you talk about your own death or when you talk about your relative's death then immediately you have certain standards coming in isn't it?

[00:15:24]Have you asked yourself the question that where would you like to die? I mean given a choice given a choice where would you like to die at home in a hospital in a ICU in a hospital? given a choice if you if suppose I am Yamraj the god of death and I I I give you that boon that you are free to choose your place of death so what would you choose for yourself but then once we all know what you're going to choose right most of us would choose to die at home in the comfort of home surrounded by by our family members without pain right so many factors would come in but when it comes to our patients.

[00:16:07]They are left to die painful deaths in ICUs, undignified deaths in ICUs, lonely deaths in ICUs, very very very expensive deaths in ICUs.

[00:16:22]The reason why I chose anesthesia was because I loved intensive care medicine.

[00:16:29]And over the years practicing intensive care medicine, there was a point of time when I realized that there was something very wrong about it.

[00:16:40]And that is when that was my calling.

[00:16:42]And way back in 2003 2004 I I chose the path less traveled and I chose the path of paliative care.

[00:16:55]This is from ancient India yaka yashka in the fifth century they had described the six phases of life. The moment the embryo is implanted in the womb it is called ai. Life begins at that time. Then Jay Jay means when the child is born.

[00:17:18]Then the little child grows up. Then that is the child matures. Then the child the fully grown person now starts decaying.

[00:17:34]And then finally vinayi our body is destroyed.

[00:17:42]At the base of everything there is a statement which says that that which means that everything which is born has to die.

[00:17:55]And of course this statement is followed by another statement which says that whatever dies again comes back to life.

[00:18:03]whatever dies I mean there is something in us which never dies but that's that's a different story and uh we'll we'll not talk about that now but see when we study modern medicine we have been taught all along that death is somehow we view death as a failure we will do everything to prevent death but somewhere along the We forget the fact that death is physiology, isn't it?

[00:18:37]Death is physiology.

[00:18:41]Whatever whichever thing is born has to die, has to perish at some point of time. The physical body perishes. Right?

[00:18:51]So death is physiology. Some way pathology there is a pathology or there could be multiple pathologies contributing to death.

[00:19:02]So paradoxically so many pathologies contributing to the ultimate physiological event called death. But then death is physiology. Death is not pathology.

[00:19:12]We need to focus there.

[00:19:15]So please please and please give death a chance.

[00:19:22]You cannot beat death.

[00:19:26]The last days of our life, the last days of any person's life, maybe some of our most significant providing opportunities to create final memories, give final gifts, find spiritual peace and say goodbye.

[00:19:43]And this is what the family remembers most for a long time after the patient's death, the last days of life. If you reflect back on your you know ancestors who have passed away your say maybe grandparents or who who have passed away those last few days those are remembered very fondly you know or maybe even sadly if the patient has died with a lot of pain or in agony uh especially during covid where you couldn't even you know acknowledge the person people were stripped of their dignity So you see if if you ask yourself I'll give you another scenario now suppose you just have 3 days to live 3 days after 3 days you're going to die right so in these three days you just have 3 days focus on that you just have 3 days to live after 3 days you're going to die in these three days of your life What do you really want to do in this 3 days?

[00:20:53]All of you would have different strategies, right? I want to do this. I want to go home. I want to, you know, spend more time with my children. This that or I want to, you know, roam about the world. Whatever. It could be so many things.

[00:21:09]My question is that all these desires which you want to be fulfilled, want to have fulfilled in these three days, why don't you do it right now?

[00:21:22]What is the guarantee that you will actually not die after 3 days? You might actually die after 3 days.

[00:21:30]So whatever don't keep waiting people you know the greatest folly most people do is that oh we will I mean after retirement that is the greatest joke of the century you simply can't do it you would be really very very very lucky if you can actually do that to whatever because the last days of life are so very important. There was this study uh in uh in the UK I believe UK or in the US uh where nurses uh they they interviewed patients uh before death you know and uh they are those patients they interviewed who were on the verge of dying and they asked them are there do you have any regrets in life and most of these patients had so many regrets.

[00:22:35]All of them said that is the saddest way to die. Dying in regret.

[00:22:48]One should not die in regret.

[00:22:51]That is a part of quality of life.

[00:22:56]So what exactly is paliative care?

[00:22:59]Paliative care is not something which says that oh you're going to die. Okay.

[00:23:04]So anyway I'm going to fac facilitate your dying. It's not that it affirms life. See piative care the first thing is it affirms life and regards dying as a normal process. Physiology. Death is physiology right? It neither hassens or delays death and it provides symptom control and not only symptom control from a physical aspect.

[00:23:28]It addresses the person as a whole. It addresses the person as a whole, right?

[00:23:34]The physical, psychological, social, spiritual, emotional and not only the patient, it acknowledges the caregiver because most of the time the caregiver suffers more than the patient.

[00:23:51]patient.

[00:23:54]But the caregiver at that time he or she was providing the care process.

[00:24:12]we call is grief.

[00:24:15]There is an erosion of the soul out there.

[00:24:23]So what exactly is end of life care? The GMC UK defines end of life care as approaching the end of life as when a person is likely to die within the next 12 months. So ask yourself that surprise question. Would you actually be surprised if this patient lived for one year? If the answer is no, then you should immediately start end of life care.

[00:24:51]Tell them to if he wants it, he can go home, spend quality time with his family, do all those silly things which he which he always loved to do. having that ice cream or you know basking in the sun or taking a bath in a swimming pool or a dirty pond doesn't matter.

[00:25:13]The Indian Council of Medical Research defines end of life care as an approach to a terminally ill patient that shifts the focus of care to good symptom control. Shift this is all about shifting gears.

[00:25:28]Top gear low gear.

[00:25:31]So shift care to good symptom control, comfort, dignity, quality of life and quality of dying.

[00:25:40]Nobody talks up about quality of dying.

[00:25:43]I'm sub quality of life. Quality of life. But quality of dying is so very important.

[00:26:04]without your clothes.

[00:26:17]Whatever it is, choice, you have to make that choice. Make it happen.

[00:26:24]Start from yourself.

[00:26:27]You are the most important person in your life.

[00:26:34]Remember that you are the most important person in your life.

[00:26:43]Be a little selfish. It is good to be selfish at times.

[00:26:49]You set certain standards for yourself and those standards can then be transferred to other people.

[00:26:57]So it is it is like a good standards you're setting for yourself. Right?

[00:27:07]So death is inevitable but suffering is not. Right? So we talk about death but whichever way it is not always physical pain.

[00:27:23]People are in pain but it is not always physical pain. Physical pain there was a study which showed that out of in chronic pain especially the physical aspect of pain accounted for around 25 to 30% of the total pain. That is about it to 70% of the pain 70% of the pain which is psychological pain social pain and spiritual pain people don't want to talk about it but 70% you are not addressing 30% pain billions and billions of dollars are being spent so much research interventions you do you know perccutaneous techniques ultrasound guided techniques and what not and what not what are you achieving 30%.

[00:28:16]S% psychological aspect spiritual aspect social aspect of pain nobody addresses or you are not interested because there is no money in it there is no industry but pharmacological industry to back you up 30%.

[00:28:35]focus.

[00:28:38]So focus focus makes a makes a huge amount of difference for the patient.

[00:28:47]patient.

[00:28:49]What type of a doctor would they prefer degrees?

[00:28:57]But for a patient, they prefer a doctor who would listen to them, who are compassionate, who would respond to their phone calls even at odd hours.

[00:29:14]That is what they want. That is their need. But are we addressing their needs?

[00:29:24]So there is pain, there is suffering all around asamatana that are there are four noble truths.

[00:29:32]The first noble truth there is pain and suffering in the world. Second noble truth that all this pain or suffering has a cause.

[00:29:45]That is the second truth. The third truth that I am telling you about a path. If you follow this path then you will be free of suffering. Four noble truths.

[00:30:08]Now what is the role of curative treatment in lifelimiting illness?

[00:30:11]Curative treatment in cancer only 20% are helped by curative treatment. That this uh statistical figure might have increased by another five or 10% in the recent years. Endstage renal disease 6% are helped by transplant. In HIV AIDS around 30% are held by art.

[00:30:32]But in all the above situations the need is for good comprehensive care including paliotative care throughout the entire course of illness right from the point of diagnosis and not ending just by the death of the patient. It continues beyond the death of the patient because the caregiver is still there. The family is still there.

[00:30:57]Those who have cared for the patient they are suffering even more than the patient.

[00:31:05]End of life care the Lancet it was published in Lancet in 2012.

[00:31:11]Despite several reports and guidelines over the past few years on the importance of managing end of life care knowledge and confidence among hospital doctors is still far from ideal. when looking after those in the last few days, weeks, months or even years of life.

[00:31:29]We don't want to focus here.

[00:31:32]This is not economically viable for us.

[00:31:36]As I said pain maybe we are focusing on that 30% 25 to 30% physical pain because the pharm pharmacological industry is focused out there intervention short-term reliefs but long-term the psychological aspect spiritual aspect social aspect underrated.

[00:32:01]Now we come to trajectories of dying.

[00:32:03]how we die. The trajectories are basically the paths taken in which we die. The graphical part right one is the first one you see the functional competence the first the functional level of the patient has been high and young patient so sudden death. So second is terminal illness like cancer.

[00:32:34]You're diagnosed with cancer and then you see the graph coming down slowly dwindling down and uh and then finally it ends in death.

[00:32:44]Third is organ failure where the functional capacity of the patient is low right from the beginning and as organ failure progresses say a patient with COPD he would have multiple hospitalizations and after each hospitalization his functional capacity would actually be going downhill downhill gradually. So the graph you see is going downhill with sudden dips.

[00:33:10]These dips means are acute exaggerations of COPD for example and finally dying.

[00:33:19]And then there is a fourth graph where there is a low functional capacity very low functional capacity right from the beginning and it is a very slowly dwindling type of dying like you see in dementia uh um or uh um you know uh failure to thrive those those uh type of situations. [clears throat] Then there could be a fifth one where there is a high functional capacity and then there is a catastrophic event like a stroke or a hip fracture in the elderly and the graph goes falls down steeply but it doesn't test the baseline and then the patient dwindles on and on and on till the patient finally dies. So basically this this uh graph is a combination of two graphs. It is a combination of the sudden death thing and uh uh the dwindling type of uh thing which I showed you the fourth graph.

[00:34:19]So coming back to the shifting of gears the surprise question as I told you right we also have to focus on what are the potential benefits of treatments versus potential burdens once we understand that this patient has approached the end of life care has entered the phase of end of life care we need to be justified we need to be ethical in our decision making striving to preserve life but when biologically futile providing comfort in dying and individual focus on individual needs versus those of the society.

[00:35:00]You know uh in our center in rural Jharkhan we also run a old age home right up old age home getting senior citizens is so problematic so problematic we cover 28 villages right 28 villages in the Bokaro district of Jakart we try to identify the elderly who are bedritten but We tell them we look after them till they die. We ensure that they they will be there in peace.

[00:35:53]They can't afford to keep them happy, to keep them wellfed. They are malnourished, elderly, poorly looked after.

[00:36:08]But this is the sad situation, right? So needs of society that is needs of the society. Focus on individual needs rather than needs of society.

[00:36:28]This is our hospice and uh this lady who you see who is lying on the bed has just passed away and we get those village girls as a part of women's empowerment in our center and 6 months training as to how to take care of a bedritten patient.

[00:36:57]You will you you are not going to die immediately. Right?

[00:37:01]If you die of old age also there is a period of around 2 years 2 years time when you will require support with activities of daily living.

[00:37:17]Now the question is that who is going to provide this support husband wife say to now who is going to take care of you forget about it they are not going to take care of you don't even expect that now the question is who is going to take care of you then manower to we are trying to create create a a system manower.

[00:37:54]So we train this village girls how to look after a bedridden patient right to provide comfort care.

[00:38:02]Okay.

[00:38:05]So these are our uh village girls again providing comfort care.

[00:38:10]So the aims of treatment out at that point of time in end of life care to is see the aims of treatment to make the person as comfortable as possible.

[00:38:22]As comfortable as possible means no dietary restrictions, no visiting our restrictions, no hospital dress.

[00:38:36]If you want a drink also once once in a while I will supply that also to you. if you really need it right to say for example up today you are used to an air conditioned comfort you want your AC uh bedroom you want a very clean toiletage home you have to share your living room with 10 other other people and there is just one washroom one smelly washroom are you are you ready for That are you ready for that?

[00:39:18]You would like to continue in that fashion itself. Isn't it? But investment that is your what I call the death that death insurance. You have not invested a single in that one event of your life which will definitely come with a guarantee.

[00:39:50]Your stocks can rise, can fall. Beta can look after you, might not look after you. You can buy a car, might not buy a car. But to death, you see, is not a switch.

[00:40:07]On, off, on, off.

[00:40:13]It is aa it is it's a process say which progresses over a couple of years in which physical body.

[00:40:29]You would require increasing support levels for activities of daily living.

[00:40:41]But period important and that is why there is something called the advanced directives which the Supreme Court has legalized now.

[00:41:00]Advanced directives Then who will take the decision?

[00:41:32]I have kept my father in ICU. 50 lakhs I have spent with pride with his hands restrained with a tube shoved down his throat.

[00:41:49]Not a very good situation.

[00:41:52]So if you want to make a difference in your last days of life then there is a legal way to do it and that is advanced directives. Write it down though person nominees. Nominees in terms of not nominees exactly but executors of your will. Those could be your wife, your husband, your son, your daughter or even your best friends or is go any gadgeted officer can sign it and it becomes a legal documentational witness.

[00:42:41]Those are now legal documents, advanced directives about your own wishes.

[00:42:48]You're free to change it again.

[00:42:53]Cancel out the previous one, make a new one. Doesn't matter.

[00:42:57]Right?

[00:43:00]So these again are our uh those village girls whom we train and uh home visit the dying. know we are not God. All they ask is that we do not desert them.

[00:43:22]Okay? We want people by our side because death can be so very frightening.

[00:43:39]Right? Even the best of syases and rishies they also die in the company of others.

[00:43:53]Nobody wants to die. So plan planning about how you invest and spend your last days of life.

[00:44:08]So the question again arises that will we die in a manner consistent with the way we lived which respects our personal values, spiritual beliefs, cultural backgrounds and preserves our dignity.

[00:44:21]So that is again very important. Now he he used to live in northern part of Bihar like Samastipuru said and he had come all the way from northern Bihar to Bukaro because granddaughter Shad was a patient of COPD also and then He developed an acute exervation.

[00:45:04]Within a couple of days, he was okay.

[00:45:08]Fit to go back.

[00:45:29]But granddaughter that was his wish. So the son did not come to take him back. And every evening this this old man he used to sit during the visiting hours But that sadly never happened. And the granddaughter got married. The Buddha continued in the hospital. And then he developed another exervation. He was put on ventilator.

[00:46:05]Then he didn't make it. He passed away in the hospital.

[00:46:10]So that there could be so many different stories like this.

[00:46:19]Now place of death and [clears throat] correlation with quality of life. Yeah.

[00:46:26]The yellow decipers home and the red one decipers the intensive care unit. So people had the best quality of life when they died at home.

[00:46:40]They had the maximum physical comfort when they were at home with hospice with intermittent hospice care and they had the best psychological well-being when they spend their time at home. So home is the best place. I assume a quality of life was worst, physical comfort was worst, psychological well-being was worst.

[00:47:14]So these this photo again uh was from my very early days. You can see the med medicine ventilator out that that medivvent.

[00:47:24]This was way back in uh 9697 somewhere some sometime and uh this was a child with musculardrophe and uh some very clever person decided to put this young boy on ventilator and uh he just remained on ventilator and he spend his last days of life in the ICU only to mib I used to go for rounds you know and he used to follow me with his eyes just focus on his eyes he used to follow me with his And I used to feel so ashamed of myself IV so that he could sleep at least so that he could be in peace so that he could sleep he could be relieved of pain.

[00:48:17]I used to talk to him also.

[00:48:21]So this is a way of dying in a ICU. The second way of dying, this is our hospital in rural Jharkand. You can see this lady uh she has a large abdominal tumor and all these girls whom we train the village girls. They are actually giving her a foot massage.

[00:48:46]foot massage. We focus on these hands-on nonfarmacological methodologies of treatment.

[00:48:54]This non-farmacological methodologies go a very long way in alleviating pain and suffering.

[00:49:03]So second way of dying in a hospital.

[00:49:07]And the third place of death at home.

[00:49:13]This is one of my very favorite slides actually.

[00:49:16]So this lady dying at home lying on the chari that is the husband and our team is sitting on the chair and the whole extended family is surrounding her.

[00:49:40]This is a beautiful way of dying you know dying in peace dying in comfort dying without pain surrounded by the people whom you love. It's a beautiful way of die choice.

[00:49:55]So how to diagnose dying? It is not possible to predict with certaintity and of course there is a reluctance because we often look we have been trained that way that death is a failure of medical treatment.

[00:50:10]treatment effective.

[00:50:13]So there is a reluctance to diagnose dying.

[00:50:17]Most of the studies which have been dying which have been uh done were done on patients with cancer.

[00:50:25]So patient becomes profoundly weak essentially bed bound drowsy disoriented disinterested in food and fluids having difficulty in swallowing medications around maximum two months difficulty in swalling medications two months.

[00:50:51]So uh there are various scoring systems also like the Barthol score is there right now. This was another study which was done by Licar and Hunt. This was done they just documented the symptoms in a series of 200 patients who were actively dying in a hospital. 200 patients who were actively dying. Right? series of 200 patients they could be dying of whichever cause. So most prominent symptom in the last 48 hours of life noisy and moist breathing in 56% patients urinary dysfunction 53% pain 51% so on and so forth.

[00:51:37]What this actually means is that every second person listening to this lecture would be dying of disna or you will pass urine in your pants or in your bed before death or you will die in pain and so on and so forth.

[00:52:05]That is what the statistics mean actually. And are you ready for it?

[00:52:11]Are you ready for it?

[00:52:15]So there are two roads to death. One is the normal road. The usual road where you become gradually sleepy, lethargic, obtended, semicrose, comes and then there is the difficult road where the patient becomes restless, confused. You will have tremors, hallucinations, delirium, micronic jerk, seizures and then finally you will uh you know enter the coma phase.

[00:52:43]So which road do you want? Naturally everybody wants the usual road special you will have a very good death.

[00:52:58]What preparations have you done planning investment to ensure that you have a very smooth transition into the afterlife?

[00:53:10]Let us not call it death. Let us call it afterlife.

[00:53:17]Now here you can see this patient actually sitting up focus almost you know uh You you see his very anxious gaze. This patient had multiple myoma with multiple cannonball mitts in his lungs giving him company and in between the shoulder blades. Gentle massage nonfarmacological therapy very very very effective.

[00:54:02]A patient with disna is so very scared.

[00:54:20]He's so scared.

[00:54:27]Reassure.

[00:54:29]Don't jump to start any intervention which you cannot stop later on.

[00:54:36]Right?

[00:54:40]So what is the concept of a good death?

[00:54:47]You will have your own concept. I will have my own concept.

[00:54:51]So last time also when I took this lecture, I gave them the homework. I always give homework. Homework homework.

[00:55:09]is just jot it down.

[00:55:20]And again, this was another patient of mine, a very early patient of mine, she had CA gallbladder. This lady, this patient who is lying down and because she was tossing and turning in pain.

[00:55:46]So we gave her some painkillers and when the pain came down then she could talk to us.

[00:56:01]Now this is another case.

[00:56:06]So she had CA cervix very smelly biometra biometra had been drained pain had been relieved pain the rest of the family could sleep in peace mean without that obnoxious smell.

[00:56:43]And the beta used to tell us my mother can't sleep.

[00:56:48]So what would you do? What would you do?

[00:56:55]Out of box thinking this was the cause of insomnia.

[00:57:09]So we just purchased a mosquito net gave her that and so again professor sitting with a dying patient he had come to India also way back in 2011 and uh simple interventions like this lady she had CA uh breast very advanced and great granddaughter her pain her VS scoring came down dramatically dramatically by almost 50% reduction VS score.

[00:57:57]So the physiological changes and different management principles of end of life care it's a huge I mean it's end of life care is a seminar by itself.

[00:58:07]So but gradually weakness and fatigue would increase. Patients would become bed bound and this is this becomes a source of distress for the family members.

[00:58:20]But at this time gently that you know when the body requirements are low, the physiological requirements are low, BMR is low when the body is refusing food and fluids, it is best not to push it in forcibly.

[00:58:37]Because dignity is so very important.

[00:58:40]Dignity just to please me.

[00:58:50]That is not right.

[00:58:57]They should please themselves. No.

[00:59:01]That brings us to brings me to a question that do you love yourself?

[00:59:10]Do you really love yourself?

[00:59:14]Ask yourself that question.

[00:59:17]Do I really love myself?

[00:59:22]You'll be surprised by the answers.

[00:59:27]Paliative sedation versus euthanasia.

[00:59:30]You know palative sedation is a is a very important part of the arbitrarium which we have and as anesthesiologists it is our job to know a lot about paliative sedation right. Use of drugs to relieve suffering not to terminate life. Intent is to provide comfort.

[00:59:50]Right? Sanctity of life is always upheld.

[00:59:54]Death may be hassen by paliative sedation.

[00:59:58]palative sedation patient. But what was your intent?

[01:00:05]Your intent was to provide comfort to the patient. This is called the double effect. The principle of double effect, right? So this is ethically justifiable and a part of good paliative care.

[01:00:22]So attending to those little things you know being surrounded by the family members how do you know do you are you an authority? Have you read anything about religion or spirituality?

[01:00:48]Do you know the difference between religion and spirituality?

[01:00:52]Big topics but we should we should know something.

[01:00:59]So here I am u explaining to two family members simultaneously as to how to administer intermittent subcutaneous injections.

[01:01:11]patient in terminal stages cannot follow.

[01:01:15]IV start is easy but maintain is difficult because an IV is a technically technically special thing right. So it is easier to give intermittent subcutaneous injections. What I do is I insert a butterfly uh needle in the infraicular uh fossa and I leave it there and the drug is prepared in a syringe and given to the family member.

[01:01:55]So this is a beautiful way to take care of severe pain at home.

[01:02:05]loss of sphincter function. This is the most distressing thing and the most uh dignity you know provoking thing which is beyond your control and waiting for somebody to clean you up. that waiting that person but what happens to you as the patient out there you are so ashamed and you can do nothing about it.

[01:02:46]So this is how we nurse our patients in the lateral position. So that drooing of saliva be uh so in the lateral position or in the recovery position. Uh the saliva droo saliva is collected on tissue papers. You can see below the angle of the mouth tissue papers are kept and that can be removed. And you can see that uh uh butterfly needle fixed in the infraular fossa.

[01:03:12]Right? I'll skip these.

[01:03:17]Patient could become restless. Now the reason of restlessness could be so many pain, pritis, uh full bladder or bubble, anorexia, dysnia, so many things. So we need to find out what is the cause of restlessness. Right now there was something called the Liverpool care care pathway which was uh developed in the 1990s in Liverpool in Liverpool. Uh there is a Mary Cury hospital out there.

[01:03:47]So this was again changing the gears.

[01:03:50]They were more f they were focusing on comfort measures like there were certain goals in the Liverpool care pathway. The first goal was to review medications maybe one month calcium complex.

[01:04:08]So you can cut down review your medications. Second goal drug therapy as per protocol. Third goal was to discontinue inappropriate interventions, document DNRs, right? So on and so forth. Then ability to communicate, fifth goal, insight into condition assessed, so on and so forth.

[01:04:29]But then the Liverpool care pathway uh on a long run came into a lot of uh critique because uh many doctors and nurses were following it just as a protocol based instead of you know uh instead of focusing on the real reason why the Liverpool care pathway was designed they were just focusing on the Liverpool care pathway as a protocol.

[01:05:00]So that uh that actually didn't serve the goal and now what we have is personalized end of life care plans like personalized planning that's that sort of thing you know uh recently there was this concept uh in the UK where patients in the ICU where the whole bed was shifted out into the garden into the rooftop garden so that the patients could be at one with nature.

[01:05:38]Now we have pet therapy. Pet therapy actually. And uh you won't believe it.

[01:05:44]This was way back in uh 1999 probably 2000 in our ICU in Bukaro where uh there was this bada and his mother was dying and he took special permission and the black ga the calf I held the tail of that calf.

[01:06:18]But I have stopped laughing now because that that was religious and spiritual care.

[01:06:27]It has religious importance in Hinduism.

[01:06:36]So that is a religious belief.

[01:06:38]There could be so many religious beliefs like prayers, tying a black thread.

[01:06:47]But because it is not being done for you, it is being done as as per the wishes of the patient.

[01:06:58]We are addressing that those are personalized plannings.

[01:07:04]That is why they are important. better communication, free frequent reassessment, symptom management, ethical safeguard, so on and so forth.

[01:07:12]Ask yourself these questions. What is the prospect of life? What is the aim of my treatment?

[01:07:29]Why? What is the aim of treatment? What is the risk benefit ratio?

[01:07:36]And will your intervention lead to a lingering death?

[01:07:41]Will it prolong the process of dying rather than giving life?

[01:07:48]So focus on that.

[01:07:52]So you need to anticipate, you need to prepare, you need to face the event.

[01:07:57]And then story doesn't end there. The patient family bereiement. So bereavement care is also very important.

[01:08:09]So uh as I talked about religious concerns and so on and so forth, I think I'll end here now just by saying that life insurance or death insurance your investment in things which really don't matter, really don't come with a guarantee or your investments in your last days of life which will definitely come with a guarantee. The choice is yours. Thank you.

[01:08:41]>> Such a wonderful lecture, sir. Such a deeply poant and thoughtprovoking uh lecture. It made us think of our own end of life actually. And as you rightly said sir, we are not scared of death.

[01:08:58]But then we are only scared of suffering before death. And as you rightly said that we have to plan our death and you know and uh make appropriate arrangements write proper you know will accordingly and all that and u and again another thing as you said is about the dignity.

[01:09:26]You're so worried about being totally dependent on someone else especially when it comes to you know cleaning for urine motion.

[01:09:37]I mean it's such a hopeless uh feeling such a feel such a loss of dignity after having lived a respectful life. I mean it really make made us think sir and I'm really really thankful to our president that you know we had this lecture and you know it made us it made our you know it opened our eyes and uh here I would like to share that we have one other anesthetist one Dr. Dr. Balaji Asagonar and his team they also run a hospice called Sneighha Savi and I had the pleasure of attending that and I could see everything of what you said sir I could see all of them and uh one question I had sir my I remember my mother when she before she died she took a promise from me saying that there should be no tubes in me. I don't want any tube. Let me die in peace.

[01:10:47]And what happened was I came home for a few hours. My sister had just come from US. She was taking care of my mom. She didn't know that. And my mom suddenly arrested. Then she was intubated and she was in the ICU. When I went back and those eyes which saw me at that time, I can never forget that guilt which I carry even today because it looked as though she was saying why did you do this to me? you know that I thought she was giving me that kind of an expression to me and supposing something like this happens after uh after having promised my mom that okay no tubes what can we do?

[01:11:39]Yeah. Now there's been a recent uh Supreme Court decision regarding uh uh withholding or withdrawal of life sustaining treatments uh especially if you have an advanced medical directive in place which is now which is so very important then the whole process becomes very simple.

[01:12:01]However, if an advanced medical directive is not there, then the treating doctor will take the call, you have to uh talk to the treating doctor and if he decides that there is a futility of treatment of further treatment out there and he can document that then he starts he begins a process. Then you know then there is a primary medical board which is constituted within 48 hours with two of his colleagues who have at least 5 years experience in uh intensive care and they will review the patient and the treatment protocols and once they are convinced then they will constitute a secondary medical board and uh the secondary medical board is constituted by the hospital chief medical officer and uh once they also come to the same decision then the decision is given to the high court and then the high court responds back and then you can withdraw all these life sustaining uh therapies. This is the legal way to do it now.

[01:13:09]>> Yeah. But it's such a longd drawn process sir.

[01:13:11]>> No now with this with the advent of this now this has been shortened down to about a week. Initially it used to take almost a couple of months. So now this has been shortened down to about a week.

[01:13:24]So 48 hours for the primary medical board, 48 hours for the secondary medical board and uh then it goes to the court and the uh thing is done. But still I mean it is uh a uh withholding of treatment is slightly better than withdrawing of treatment. So it is better not to start oxygen therapy in a in terminal disna rather than starting oxygen therapy and then having to withdraw it. Although the legal implications of both these acts are the same but it is better to withhold rather than to withdraw. So >> in fact I even requested whether they can completely sedate her and I will hold the mask you know you exubate her I will hold the mask we'll give her CPAP and see we'll do all that but ICU doctors they will not agree with you sir.

[01:14:17]No, you cannot.

[01:14:18]>> I don't think it's so easy to withhold uh and it's easy for them to say that no this treatment is never going to work for this person.

[01:14:28]>> So they are not going to say that >> there is a reluctance there is a reluctance and there is a fear. So but >> they are not going to say sir they won't say that.

[01:14:36]>> Uh they they will not accept that. That is very true. But now with this uh you know supreme court judgments coming in uh these things would gradually over the years we will and that is why it is so very important for all of us to have our advanced medical directives in place. It is so so easy. You just need to have two witnesses and one gazetted officer to you know sign it. That's about it.

[01:15:02]>> So is it not equivalent to euthanasia?

[01:15:07]>> No no no. See this is this is in a way this is passive uh you can call it passive euthanasia but uh the the uh Supreme Court has allowed it. It has not it has allowed this is uh we don't actually are not using the term euthanasia here we are using the term with withdrawal or withholding of uh treatment withdrawal or withholding of treatment.

[01:15:34]Yes, same thing. Finally, we withdrew all the inotropic support. We said no inotropic support. So that's >> that you can make a call. Yeah.

[01:15:43]Gradually and then you can maybe shift to just ATPs uh or by uh then that sort of thing gradually.

[01:15:55]>> President sir do you relevance of just a minute.

[01:15:58]>> Yeah.

[01:15:59]>> Uh sir, what is the relevance of living will like you know that Dr. Indrani said her mother said no tubes nothing. So if you write something like that and if it doesn't reaches to the doctor or treating physician if it remains with the family members then what is the how can this be uh possible then unless your family members they give your living will to the treating physician. Uh how is that possible? Means even if you have declared that that I don't want this kind of life at the end and uh that what is what is the uh alternate for that?

[01:16:42]No, it is not an alternate. See, you have to take the path like anticipate.

[01:16:51]So instead of involving your family members, you can involve two of your best friends also. [clears throat] You have to have family members al only because if you have a doubt will not follow what I write or my wife will not follow what I you know I'm writing down in my will. So you can appoint two witnesses who are your best friends who will take this living will document and show it to the doctor once you are in such a state where you can't you know voice your own preferences to document you need to submit it to your local municipal corporation office also so that the moment you are hospitalized or in a hospital of your preference you know health insurance whatever it is or a hospital of your preference that sort of thing. So it is important to document your advanced medical directive and to enforce that you need to choose two witnesses.

[01:17:53]That choosing of two witnesses that is the most important part of it preferences that is more important. That is important. So it is you're empowering yourself itself.

[01:18:10]>> You have the power Uh sir I have a question for you. May I ask you please?

[01:18:17]>> So what happens that if a patient has given a DNR orders are there but in an emergency situation or in during a coding somebody intubates the patient or does a CPR so what are the legal implications or any other implications on that matter?

[01:18:31]>> Just let me know once you find Leela.

[01:18:34]So uh once uh if a DNR consent is in place and it is documented >> but still somebody uh some very clever person comes and does the CPR or intubates the person then the family can actually see you as simple as that.

[01:18:57]Like you know a patient might have allergies and if he has documented that it is our duty to in the pre-anesic checkup we have to put it up in bold letters we have to flag it. So similarly you need to flag it >> right. Thank you so much sir. Over to you Indrani ma'am.

[01:19:16]>> Dr. Dham Dr. Dham uh since it's a online PG class so I just want to recapitulate.

[01:19:22]Yes, we're talking of uh suppose uh now getting to the more practical and theoretical terms that if such a short note comes in uh in the exam. So my based on his talk my suggestion to you advice to you is please when you talk of end of life care do talk of complete pain relief whether it is by oral medication by patches by subcutaneous or by doing minimally invasive pain and spine interventions like celices block so that whatever life god has given is painfree. Second is management of the symptoms whether it is wounds, maggots and uh diarrhea feeding at the same time don't overfeed and ensure that bowel and bladder are at are adequately taken care if there is no control by cathization and diaper otherwise uh by by with by the help of the domestic maid. Fourth one will be emotional and uh spiritual support. Same time firmly believing in the religious beliefs and importance of hospice care so that patient has got good quality of life uh good dignity of dying uh at home or atospice so that the whole concept of end of life care uh is taken care of. uh if I missed something sir you can please add on to that.

[01:20:54]>> Yeah. Uh in addition to that I will just add this concept of uh total pain as yeah as uh expounded by Dame Sisy Saunders. So in that total pain the physical psychological social and spiritual. So total pain can even be a short note or whatever.

[01:21:14]>> So so please do mention about total pain and it includes everything >> right. Yeah, >> physical, psychological, spiritual, emotional, uh all total pain relief concept. And now with the uh uh and if you add withholding of treatment or uh withdrawal of treatment uh that is also legally permissible. Don't use the term active euthnesia where we administer drug uh so that heart or respiration seizes that is still not allowed in India but withdrawal and uh withholding of treatment is uh legally allowed and the importance of DNR. Uh parl there are certain questions also which have come on to that.

[01:21:54]>> Yes sir. So there's a question by Dr. Bumika she she wants to know that which death at home in old age in their last day for painless death and sedation they ask for it. So can we do it at home?

[01:22:07]>> Uh so you uh the uh you can provide symptom relief. Right now if a patient asks for sedation you need to find out as to why what is why is the patient asking for sedation.

[01:22:26]Either the patient is having some uncontrolled symptom. So we should be addressing the symptom rather than just uh just his complain of if if the patient is very anxious and all. Yeah, you can maybe give a short dose of some benzoazipene say sublingually or you can give a spray.

[01:22:49]So that takes care of anxiety. But if it is say delirium then you take care of delirium. But if you should always look out if there is an underlying pain element or or if there is a full bladder or bowel or whichever issues and then of course there are some other issues uh which you know end of life dreams and visions something which is very close to my heart and which I have researched into but then that would need u much more different level of expertise. Um but then uh and then of course you can always call for help. So interventions can be done at home but you need to find out what are the causes what what do you think is the main symptom and what are the co underlying cause of that symptom and then try to address that.

[01:23:34]>> So so Dr. Bhumika also says that I have she advises fentinel patch and some basic critical care at home. So is it legally viable or is it such treatments are they legal? Of course.

[01:23:46]>> And as an anesthetist, can she give all these treatments?

[01:23:50]>> You can unmute yourself and interact with sir directly also. Yes sir, please.

[01:23:54]Sorry, please reply.

[01:23:56]>> Absolutely. If fentanyl patches of course you can uh prescribe but uh just one word of concern is that when a person enters the terminal phase of life their fentinil patches actually don't don't work because there is a peripheral circulatory failure. So the extremities become cold and cool. Right? So fentinyl patches how do they work? By subcutaneous absorption of the drug. So yeah, subcutinous absorption becomes very poor and it is ir reliable at all. Right? So instead of using fentinyl patches at this point of time it is better to use uh some subcutaneous or intravenous uh injections I prefer using agonist antagonist group of drugs uh compared to pure agonist when I'm giving parental medication uh because uh that little factor of safety is always there uh choices would uh choices can vary uh so that is totally up to It depends on what type of pain you have to grade the pain.

[01:25:05]The V scoring is important. Uh you need to follow the WHO step ladder of pain management. Don't directly jump jump to step three. Right? Focus on the resources which you already have locally available, acceptable, affordable and only then focus on things which are you know out of the ordinary. So focus on things which are readily available first which are affordable acceptable right. So that is how you need to go >> and can I add on to here? uh even sir sometimes patients you don't have an IV excess >> and uh uh patient uh is not accepting orally and uh even ry tube is inserted and still its feeding is not possible or patient is not letting Ry tube and if you got availability of tablet morphine which as uh anesologist we can easily prescribe by filling that form and uh never advising more than 100 tablets uh at a time and they can be bought from a authorized uh medical shop. Uh you can just break it and uh in a powder form, mix it with the honey and put it sublingually >> right that absorption can be there. And uh nowadays uh ministry of uh Aush it's not alopathic uh has also started cannabis drops also which are for uh sublingual use and you can start from as low as one drop HS to go as one drop BD TDS Q and then gradually increasing to two drops HS two drops BD TDS and going up to as high as 20 drops. So these are all uh supportive measurements and as Dr. Dham rightly said that it depends upon what resources you have and but you will be finding at times patients who don't uh IV line maintenance is difficult and uh >> oral absorption is not there patches either patient is having fever or it's they are cool.

[01:27:15]>> So if the patient is having fever infection is there some sort of infection is there then absorption will be very fast and patient will be sedated and drowsy. So you can use these methodologies also.

[01:27:28]>> Okay sir.

[01:27:29]>> We have a suggestion from Dr. uh Vive.

[01:27:33]She says acquire a basic paliative care formal training example like FCEPC which was previously called as CCP EPC by IAPCA etc like a six month online or 15 days on-site program and always take a prior informed uh comprehensive consent along with a preferable uh video consent explaining the goals and limitations of pharmacological care and homebased hospitalized care. This is medical legally wise decision.

[01:28:02]Yeah, very true. Um because nowadays it's more of a defensive medicine which sadly we have to practice. um uh but then uh I would always uh say that always remember that 30% 30% of that pain is physical address that 70% also if you have that fear uh of administrating or if you don't have the resources of getting morphine or fentinyl patches uh but still you can still focus on the non-farmacological modalities of treatment it is Not always that dying patient that that you have to do something even the whole family knows that the patient.

[01:28:52]They want acknowledgement.

[01:28:55]They want to you know talk to somebody acknowledge my my personhood that maybe acknledge.

[01:29:08]So that is so very important and don't forget the family members family members don't forget the family members talk to them right till the time he set it or is taking it forward for the postgraduates also yes we as anesthesiologists are not commonly involved in breaking the bad news to the attendants which is usually done by the treating doctor but at times you may encounter a scenario where you may have to tell uh about the uh prognosis.

[01:29:50]Yesterday only there was a uh patients attendants came with a file and uh widespread metastasis on PET scan and uh scumosal carcinoma on esttopathology and they just came with the a report and so I had to break the bad news to the to the to the wife and the kids.

[01:30:16]They were thinking that it may be tubercular but report a right. So they have that those things. So you should be very very compassionate in in in telling the tendants also and definitely they will be very very shocked and surprised.

[01:30:32]So you have to console them also and tell them but I just want s your inputs. I personally believe that we should not hide.

[01:30:42]Kar relatives says don't tell the patient but I say okay don't tell it now but tell it in due course of time because he or she may be having something in his mind or heart I have to say thank you to somebody or I have to say sorry to somebody or I have to fulfill that old desire or there are some legal things to be done so what is your take on that sir >> that's a million-dollar question uh this is what we call the conspiracy of silence But he doesn't talk to the father. So both of them you know uh we need to break it but then gently. Yes >> and fixed protocol.

[01:31:31]It should be individualized approach.

[01:31:38]Give them broad hints.

[01:31:41]And uh the best way is to tell ask the son if the son says to ask him what would you want if you were in your father's shoes and often uh this becomes a you know turning point then so but then I do believe that if the patient desires to know it is your duty to let them know but Give it in small lumps. Don't so give it in small amounts the information right.

[01:32:31]>> Uh sir there's a question for you. How do you envision the establishment of economically feasible end of flight non-farmacological care system in India?

[01:32:41]come and spend 10 days in my office in rural Jarant.

[01:32:51]The answer is loud and clear right go to Kosish and see how they are working.

[01:32:59]>> So so that's all from my side. Any other question or the audience can ask they can unmute themselves or they can ask any other question they have >> or any comments ma'am >> Dr. Yes Dr. Manoj.

[01:33:22]>> Yeah sir. Uh good evening.

[01:33:25]>> Thank you president sir and secretary sir for choosing such a important and nice topic from the speaker of Bihar Jaran. I'm very really thankful to you sir.

[01:33:38]It's pleasure to have him with us and I'm very sure uh lots and lots of people will see the recording on our ISC and HQ YouTube channel and uh learn from his wisdom and experience.

[01:33:53]>> Thank you sir.

[01:33:54]>> So I think we are on time and uh thank you Dr. Dam for joining us today and uh uh it was really a pleasure uh listening to you once again and the way the compliments are going on uh you deserve all the accla uh wish you good health and happiness so that you keep on working and serving uh at your place uh and extend it outside also and uh I just want to share that uh nowadays we are having some challenges is uh an anesthesia practice pertaining to some at some instance come when some a batch of drug gets uh leads onto side effects or we have some uh adverse events during anesthesia especially in pediatric age group. So keeping that that in mind uh our next class uh we are planning to have it on uh a pediatric patient posted for simple hernia surgery undergoing lab or open surgery so that we can re-revise uh the basic concepts of management of pediatric patients which will be used for for clinicians also and which will be useful for the exam going also Dr. Rajiv Gupta the honorary secretary will share the details in due course of time and uh once again uh thank you all for attending and thank you Dr. Indrani Kumar Dr. Par and Dr. Uh, thank you very much.