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. 

Non-communicable diseases - 'Ottamooli'

Sometime in the middle of last month, the United Nations had convened a high level meeting on Non-Communicable diseases (NCDs). It is praise-worthy that the world has recognised the burden that NCDs poses to communities.

Even in a remote community where I serve, NCDs are turning out into a major force to deal with. Along with diabetes and hypertension, the most recent phenomenon that we had been witnessing is the huge number of young adults and children in whom we are diagnosing Bronchial Asthma. 

Today, in the outpatient department, I diagnosed 6 new cases of bronchial asthma. In the Indian context, one of the most challenging facets in the management of NCDs is the concept of the 'single drug concept' present in Ayurveda. I'm not sure if there is English word for that. In Malayalam it's called 'Ottamooli'

When we explain to the patient that he/she may need to be continuously on some form of treatment for his condition, the family is very much crestfallen. With bronchial asthma, it is a bit easy as I also have it - and most of the time, I take out my Inhaler and show them that I regularly use it. 

Coming to Bronchial Asthma, it is disease with quite a lot of stigma. Couple of weeks, I had a young couple who had brought their 5 year old son whom I diagnosed to have Bronchial Asthma. When I prescribed them an inhaler with a spacer, they did not realize what I had prescribed. When they brought it and came back for helping them use it, the mother started to sob, when I opened the packet and took out the inhaler. 

She told me that if anybody finds her son use it, her son would have difficulty finding a bride when he grows old. Well, it was terrible to hear that. She wanted me to cancel the prescription for the spacehaler and instead give them tablets. According to her, nobody would know that her son is on tablets. The father also ultimately started to beg me to change the prescription. No amount of counselling could help them. 

Coming back to diabetes, the attitude towards finding out a 'ottamooli' prevails. Quite a lot of practitioners have been claiming to bring about a radical cure for the disease. I've had enough patients who have come in a very uncontrolled state of diabetes after having being misled about such treatments.

With the number of patients which we encounter in our outpatient department with conditions such as diabetes, hypertension and chronic lung diseases such as bronchial asthma on the increase, the burden it is going to pose to poor agrarian communities is massive. I wonder what do we have to offer them. Or would it ultimately end up as a major business opportunity to the pharmaceutical industry - there are already signs of such a phenomenon.