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Do No Harm: The Hippocratic Oath
Room Number 3095A, Department of Geriatric Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
|How to cite this article:|
Singhal S. Do No Harm: The Hippocratic Oath. Natl Med J India 2019;32:375
At times in our medical profession, we all face tough decisions. While we often face difficulty in deciding on the right treatment, sometimes the toughest decision is whether or not to opt for an intervention. As my professor once told me, ‘It's easy to know when to start the treatment, but it is difficult and more important to know when not to.’ As someone who deals with older people and those with terminal illnesses, I face these choices often. However, four days of my life forced me to introspect on my own decision-making and pen down my thoughts.
One of the close relatives of a departmental head had got admitted under us on his request. The patient had multiple comorbid conditions (diabetes, hypertension, stroke, Parkinson's disease, advanced dementia, etc.) and had been bed-bound for the past year. This was his fourth admission in our department in the past year. It seemed that he had aspirated again, leading to aspiration pneumonia. I started intravenous augmentin and put the patient on some fluids and oxygen. Being the senior resident in charge of the case, I was answerable for the patient. However, my primary responsibility, as I realized, was not to the departmental head, but to the patient and his primary caregiver. What I saw was a gentleman in his fifties, had been taking care of his father alone at home. He had lost his job three years ago while taking care of his mother, who had then succumbed to her illness, and now his father had been struggling since two years.
Although he had hired a private attendant to look after his father, I saw him beside his father's bed when I took daily rounds. His face showed that he was worn out by the years of service and by now, he had been tested in every possible way. Tears were just a matter of time! But whenever he met me, he gave me a smile and in a stuttering voice, asked how his father was doing. You could feel the pain in his voice as he saw his father crumble by the day. Having seen patients like his father, I already knew the prognosis and was not keen on aggressive management. However, the first-year resident in charge of the patient was full of enthusiasm (and as he would hopefully realize, naivety) about treating the patient and thus wanted to start him on intensive care. The next day, when I reviewed the patient, he had deteriorated and gone into shock and oliguria. The junior resident had already started inotropes and increased the oxygen flow rate. The consultant on the rounds then decided to change the antibiotics and started him on two high-grade antibiotics. He also asked for a nephrology consultation for dialysis, in view of the deteriorating renal function. The antibiotics, as expected, resulted in an initial response and the patient was successfully weaned off inotropes. However, the patient's condition then became static, with no further improvement. While the junior resident was still adjusting the dose of the intravenous fluid and pricking the patient for arterial blood gases, I was looking at the patient and the son from a different perspective, something that was the product of years of my training. And I asked myself, ‘What am I trying to achieve here?’
Even if I considered the best case scenario and the patient's infection got treated successfully, he would still have a poor quality of life. The patient would still be restricted to the bed, with no/minimal communication with his family members. Hence, four days after his admission, I decided to start the most dreaded discussion regarding comfort care and end-of-life care.
Before making these decisions, however, you need to introspect first. You should be really sure that the motives behind your decision are pure and selfless. Decisions like these take a toll on your conscience and sanity, and it is necessary for you to have good coping mechanisms to avoid fatigue and depression. It obviously helps if you have a good mentor who can guide you and stand by your decisions, if necessary. And, thankfully, I had my faculty for support. The toughest part of your job starts once you have made the decision—communicating with and counselling the family members. You must be calm and explain the patient's condition and prognosis to them in clear and simple language. A son who has been living with his father and taking care of him on his own needs time to process the situation. Patience is of key importance here. These decisions are not made instantly. One should give a relative enough time to be able to take a decision. In their time of weakness, family members of patients depend on us and ask us what the right decision is. However, we have to remember that we are neither god, nor a judge. We need to encourage them to make a decision on their own, while we provide all the information they need.
Since I had been keeping the son informed and had spoken to him about the likely prognosis from day 1, he understood his father's condition. I discussed with him the option of ‘discharge on request’, which would mean that he could die peacefully at home. However, he said he would not be able to provide for oxygen at home. In despair, he pleaded that his father's suffering be kept to a minimum. After some thought, I mentioned the option of stopping the intravenous medication. He agreed and we stopped the intravenous fluids and antibiotics. I could see surprise in the eyes of my junior resident as he was still filling a consultation for dialysis. As I left the ward, I took a final look at the patient satisfied that I had done what was in my patient's best interest.
In the past few months, a lot of people have told me to seek better career opportunities rather than working in an academic set-up in a government hospital. And though the fame and fortune associated with the other options are always attractive, I feel it is an easy way out. I try then to remember when and why I decided to choose this profession. I remember my father treating some poor people who would come back with happiness on their faces and respect for my father. I didn't know what my father used to feel, but it always made me happy to see how my father could bring a change in people's lives with his limited resources. It was those moments that made me take up this profession. Times like these bring back those memories, and I feel happy and proud of myself. I know I am good at what I do and I love what I do. But most importantly, I think that this country currently needs people like me who, instead of knowing what they are treating, should more importantly know who they are treating.
I remember a line I heard somewhere, ‘All we want to do is help our patients, but what they don't teach us in medical school is there are so many ways to do harm.’