Diagnosis of death - Nepali Times

KIRAN PANDAY

Doctor in the house? Bir Hospital strikes in January last year, demanding security for staff
"We are not gods," the doctor said. "At the end of the day, she might live or she might die."

I was escorting a friend to a hospital on New Year's Day, who after having completed a 50km marathon complained of feeling drowsy, fell to the ground, and started having full body convulsions. The doctor's solemn assertion followed a nurse's monitoring of the patient's vitals and a statement that "her BP is normal".

The doctor's statement only emphasised that my friend was in need of serious medical attention and consent was given for any medical tests and procedures he found necessary. I probably would not have thought much about this exchange had a newly graduated doctor friend not said the following:

"Yeah, we tell patients all the time that they might die. Doctors are getting beat up all over the place when patients die. Who wants to take risks?"

The young doctor sounded reasonable, but what stood out during the exchange was the blasé manner in which the statement was delivered, as if there were no moral or ethical repercussions of an exaggerated medical prognosis.
One casual conversation is not enough to make generalisations about the profession, but it does suggest that we might have a growing problem in our society. Doctors are getting beat up all over the place. As I found out later, the hospital I was in had been vandalised and padlocked by protestors over a patient's death only a few weeks earlier. For years, doctors have asked for increased security, even calling for bandas in order do so.

There was a time when doctors worried that giving bad news was akin to giving bad medicine and wrestled over whether full disclosure was better or worse for treatment. With the increase in the assertion of consumer rights, informed consent is the new norm. But here we have now gone past the truth about the patient's illness. Doctors now feel their security lies in giving the worst possible diagnosis, i.e. death.

A consent given on the basis of false information �" blackmail of sorts when you are told you will die �" is not a valid consent. Doctors are neglecting their duty to explain to patients the true status of their condition so the patient can make an informed medical decision. Worse, when blanket claims of death are made malpractice will be harder to investigate, if investigated at all.

This is our creation. First we put doctors on the same pedestal as gods, and when they fail we resort to our Neanderthal tendencies. Hospitals can perhaps help by creating a mechanism whereby medical grievances can be taken up. Legal mechanisms to take such claims to court have now gained some precedence with the first successful claim for damages for medical malpractice last year.

I have no reason to argue that the doctor who was diagnosing my friend did not tell the truth that day, or that he didn't perform his duty. She was given good medical care, although palliative care could have been better. The salt levels in her body had been flushed out due to excessive water intake. A few days later, her electrolytes healthily replenished, she was discharged from hospital, and was gaily climbing hills and running again. What does vex me, in retrospect, is whether he did tell the truth, or had the mob killed his ability to be empathetic?

All of this comes with the caveat, of course, that doctors can never promise cures, and death is the eventual truth of all of our lives. But as someone once said we can't be casual about the truth. And doctors should be guaranteed an environment where they feel secure enough to share the truth about their patients' health.

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1. Chyangba Sherpa
Great thought indeed by Indu. Unfortunately, our educational, social, political, economical....... factors have produced these most absurd human thinkings which nowhere get along with a civilized human world.

Posted on: 14 JAN 2011 | 6:53 PM NST

2. Samjana Poudyal
Excellent thought provking article, hope it leads to some action. Nepal Medical Association officials, amongst others, .........should take the lead.

Posted on: 14 JAN 2011 | 11:03 PM NST

3. San (UK)
Wow , Indu Nepal is an amazing writer. Does she have a website or is there any other way to get in touch with her for my thoughts and comments? I read a couple of other profound articles by her and love her rhetoric.

On a side note, I haven't lived in Nepal long enough to understand the inner politics or the various underlying problems, but I am yet to read a single article that applauds a particular system or practices that has been a success in Nepal, a model for example to Nepali youths abroad. Is Mount Everest all I can talk about with my Friends??

Posted on: 14 JAN 2011 | 4:35 AM NST

4. Doctor Who
I am a doctor, not a god and I don't want anyone to treat me as a god. But lying about a patient's condition is a crime and is liable action. Just because you are threatened to be beaten up is not an excuse. Being a doctor is not just about mugging up those facts in the book. You have to be able to counsel and comfort the patient. It's a skill you have to develop over time and experience. A patient has a right to be told the truth, no matter how unpleasant. And there's a proper way to do it. And the safe way to do it is to work within the boundaries of law. Make sure that the patients' forms are properly filled, consents taken, risks explained. Doctors barely care to tell about the side effects of the drugs they prescribe, explain the complications of the disease etc. That's inviting trouble to yourself. On the other hand, patients' relatives should also know that any information about the patient's condition is strictly confidential unless the patient gives the consent to the doctor. If the patient is incapable, his/her next to kin is the one who handles all. It's the law. But in our country, every relative, friends, friend of a friend whose daughter is a doctor, neighbors etc. are so keen to know everything. It's totally wrong. Even if the patient gives consent, we can't go around explaining everything to everyone all the time. Please do keep in mind that we are so limited in our investigations and treatment (It's really frustrating) that we are left clueless lots of time. And at those times, you just need the courage to say "I don't know" instead to telling them that their loved ones is about to die.

Posted on: 15 JAN 2011 | 12:08 PM NST

5. skeptical
50 km marathon on New Year's Day?

Where, why, on what occasion?

Posted on: 15 JAN 2011 | 4:37 PM NST

6. never mind
A friend of my friend ran a marathon, reached the finish line, and promptly died. True story. The doctor was not that far off the mark.

But I also remember a time when Doctors were respected. Not as God's, you probably like to think that as sweet of backward people, but simply as top class characters, and, well, for being respectable.

Posted on: 15 JAN 2011 | 7:31 PM NST

7. Anonymous
Seeing a doctor as 'god' (the Prabhoo), hence an unquestionable authority, is philosophically and ethically problematic. Like any other profession, doctors need to be guided by their professional ethics and societal norms and not by a sense of supremacy of their profession. As doctors claim that their profession has autonomy, so should they learn to respect the autonomy of the patients. The patients should be given the right to choose the type of care and be nurtured to question the doctors. Ironically, doctors in Nepal seem not to realize that the word 'doctor' is derived from the Latin 'docere' which literally means 'teaching'. How come a doctor is so incompetent in the very art of doctor-patient communication? Afterall, a word can kill or heal a patient. In a consumer market-driven society the teaching of physicians has been reduced to training a set of technical skills to treat the 'client'. Do doctors need to be educated in the arts of healing and fostering dialogue with their patients rather than just training in the chemical correction of Na, K, Cl, pH, and HCO3 in the body fluids? Doctors heal thyselves-- it is time to shift from radical ions to radical freedom!

Posted on: 17 JAN 2011 | 10:24 PM NST

8. ramji

Doctors are to be guided by their professional ethics. Remember Doctor is not God who has no right to discriminate the patient and the relatives. Patient should be treated as per his/her consent; if the patient is unable to share the trouble he/she should be treated by the relatives consent. All required diagnosis needs to be taken before taking any action. A minor mistake leads the loss of patientï¿½s life. Sowe have heard of many stories that the doctors are beaten up in many hospitals. There should be mutual understanding and faith. Main point is that Doctors are to be educated in arts of fostering dailogue with the patients.

Posted on: 19 JAN 2011 | 11:55 AM NST

9. Durga
A nice article. It correctly explains the situation of our country. From my point of view, the only remedy is the implementation of strong rules not only the making of rules just for sake. There must be rules regarding the punishment to be given regarding the ill-treating/beating of a doctor by the patient party. And also the rules must be implemented for penalising the doctor if the there is any wrongdoing from the doctor's side then only the patient-doctor relationship can improve otherwise the relationship is going to worsen further....

Posted on: 19 JAN 2011 | 12:56 PM NST

10. B
There should be somewhere, someone or some institution that the public can turn to when there are cases of malpractice by doctors. I have seen a lot of negligent diagnosis from doctors to know better. When you have nowhere to turn to when you believe that the doctor has been negligent...it is natural that people turn violent...specially when you lose someone close to you. Doctors can not always save lives but sometimes because of their negligence, it can cost someone their priceless life. Yes, you can take things to court....but courts decision take a lifetime to come...there most be something more efficient and prompt system in place.

Posted on: 19 JAN 2011 | 4:35 PM NST

11. Salil

A person who has run a 50-km marathon can obviously have severe electolyte abnormalities and yes, it can kill a person. The doctor, or rather say the junior doctor, as implied by the writer was right in warning of some thing as severe as death, given the treatments doctors are meted out in Nepal.

The blase manner in which the statement was delivered can perhaps be explained by the fact how our medical education is imparted, partially to our culture that is not polite enough. Why blame a doctor for being blase, when the issue is rampant every where and in each profession we see. I see rude people in banks, not-so-well-behaved journalists, snobbish drivers and rueful civil servants, why single out a just-graduated doctor for being blase? One can not expect exemplary professionalism from novices, let us give them time to learn. Yes, of course when the senior doctors are rude, then it is very regrettable which most often is the case in Nepal.

People do elevate doctors to the pedestal of God, but then it is not their fault. A doctor is a simple professional who does his duties and no doctor can be a God now matter how prolific his career is. It has to be taught to the Nepali doctors who revel in the art of self glorification, engage in publicity and deify themselves at every opportunity they can. That is much more deplorable than a helpless junior doctor acting a little too cautiously.

Posted on: 19 JAN 2011 | 7:16 PM NST

12. Satyendra
If the same condition will prevail for long like the patients relatives ask for compensation in each and every case....the situation will be worse off where doctor/hospital will not entertain serious patient and ultimately people have to suffer. The debate already had started in hospital whether to entertain serious patients or not.......there are so many instance where the hospital/doctor are compelled to pay without there wrong doings......

Posted on: 19 JAN 2011 | 7:50 PM NST

13. Prakash
Like Baby Doc/Duck, Do Valor Hey Tea :)

Posted on: 19 JAN 2011 | 10:08 PM NST

14. Dr B
This article isn't about doctors, or medicine, or even the ethics of doctors. It is about a nation that has developed into a society based on "getting your own way is everything via bandh, protest, beatings, corruption, people's wars ......... even trying to cheat death or disease".

Posted on: 19 JAN 2011 | 11:19 PM NST

15. Binod
Moral of the lession...... Dont Run 50km Marathon........

Posted on: 19 JAN 2011 | 1:20 AM NST

16. jange
If it is OK to get a new constitution, agragaman and New Nepal through violence why is it unacceptable to get healthcare through violence too?

Posted on: 20 JAN 2011 | 1:14 PM NST

17. jange
"A consent given on the basis of false information ï¿½" blackmail of sorts when you are told you will die ï¿½" is not a valid consent."

Perhaps this also applies to the 12 point agreement signed with the Maoists?

Posted on: 21 JAN 2011 | 9:23 AM NST

18. KG

Liability,malpractice and negligence are big words in medical practice. Has these all implemented in nepal? No !

Every citizen has right to sue a doctor and demands legal action .Judiciary system should be scientifically sound to prove or disapprove the complaints .This way doctors will be always carefull towards their patient and they can regain their respect.

Complaints lodged to CDO office is bad ! Go to courts .If you have seen and known to bad doctors ,try to strip off their medical license with the help of court.

Vandalism is wrong way.

There is no justification for violence .

Posted on: 21 JAN 2011 | 8:43 PM NST

19. Naresh
I think this is whole lot of petty detail exaggerated for sake of one illusory yet sheeny column!

Me think the present malaise in whole lots of professionalism, malpractices and consumerism can be attributed to the mainstream, something like society's big picture.

This is not 'doctors', but 'nepalis'. At the basic level, look at our 1.percentage population of internet users 2. GINI coefficient 3.Female illiteracy 4. HDI Index. And then compare the comments at nytimes.com in Krugman's column and at nepalitimes.com in Indu Nepal's column.

Then make a reverie and resort.

Posted on: 26 JAN 2011 | 10:24 AM NST

20. Daarshanik
There must be a huge campaign in Nepal to stop the popular saying - Nepal ta ho, j pani chalcha. When it comes to someone's life, I'm sure the 'je bhaye pani huncha' mentality will not work. 'Nepali le gari khaadaina, khaayera garcha' bhanera joke garnu bhanda ta seriously attitudes ra persona change garne bela bhai sakyo. Kati din sansaar ra aafailai jhukkayera basne?

Posted on: 11 FEB 2011 | 11:09 AM NST