Dilemma

Over the last fortnight, we had 3 elderly gentleman in various stages of some form of cardiac failure. The major issue was that they were quite painfully breathless. Couple of them had not slept for days.

The amazing thing about them was that all three of them did quite well following admission at NJH in the Acute Care Unit. Fowler beds, oxygen on continuous flow through a mask or nasal prong and a comfortable climate away from the heat . . . all of them played a good part in facilitating their recovery.

The issue was that I could not shift them out to the general wards leave alone think about sending them home. The oxygen, the comfortable bed and the temperature was the major issues giving them the short lived relief.

But, then I had a very pressing issue. Who was going to pay the costs involved in such a care? Oxygen on continuous flow, regular monitoring, mechanical ventilation for one of them. The relatives were already squabbling about the inheritance they would end up having once these elderly gentlemen passed away.

We had a serious problem with one of these them. The family was quite rich. But, none of the sons wanted to pay for the treatment of their father. Ultimately, we had to go into one long session of counselling and some amount of acting from my side.

They paid up, but took the gentleman home soon after. The same happened with the other 2 patients. The latter two realised that the acute care admission of the elders in the family would result in quite huge holes in their pockets.

I don’t blame them. In a setting where the resources are limited and there were other pressing needs in the family, a decision had to be taken.

Yesterday, I had a similar patient, this time, a lady. Her oxygen saturation was just 60% without oxygen. Very much in line with our experience with the 3 gentlemen, she also did quite well in acute care with all the support systems.

The options for the family of this lady was not much. They had agreed for admission as she had a RSBY Card. We could not keep her in acute care for more than 3 days.

For her Chronic Obstructive Lung Disease, the family could not even afford a spacer for their inhaler. Our staff fashioned out one with an empty intravenous drip bottle.

With advances in technology and availability of better medicines, even the poor have started to live longer. However, costs involved in chronic non-communicable disease care is quite a lot. The fact that there are better but costly treatment modalities for prolonging life as well as ensuring a better quality of life put many families into terrible guilt as they do not want to be seen as ignoring their loved ones.

Without a strong public health care system, the costs are going to be very high. Considering into fact that our public health care systems have not been able to respond to basic healthcare issues, I wonder how fast we would be able to deal with such situations of chronic disease care in the near future.

Till that happens, families would have to think twice before they take their elderly for treatment that does not do much more than just make them feel better and comfortable.

And for institutions such as ours, it involves taking ethical decisions for our patients. And it's not the first time that we've had to ponder over our decisions regarding managing such patients.