When we were in school and in college, some sixty years ago, we were required to read at least one "Classic English Literature Work" as a part of the detailed study portions. Of course, there used to be another well-known work for non-detail study as well. These were part of the study material for English paper taught as a language subject. The non-detailed study book used to be one of the more famous novels at that time. David Copperfield, The Pickwick Papers, Robinson Crusoe, Gullivers Travels, Tom Sawyer or some other similar book. But the prescribed text for detailed study used to be usually one of the plays by William Shakespeare. There used to be Julius Caesar or Romeo and Juliet sometimes, but the usual ones were one of the four more famous tragedies - King Lear, Macbeth, Othello and Hamlet. The professors would often say that they represented the tragedy of Arrogance, Ambition, Jealousy, and Indecision, respectively.
Hamlet, the Prince of Denmark is caught in a situation where he is unable to decide one way or the other. His famous lines (known as soliloque) go like this:
To be, or not to be, that is the question:
Whether "tis nobler in the mind to suffer
The slings and arrows of outrageous fortune,
Or to take arms against a sea of troubles
And by opposing end them. To die - to sleep,
No more, and by a sleep to say we end......
His life ends in a tragedy before he can make a decision either way.
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We all have had, and continue to have, such moments of "To be or not to be...." many times in our lives. Some such moments are insignificant, especially when you look back at those issues years later. Some such moments were indeed very significant and we congratulate ourselves for having decided the way we actually did. There are also moments which called for decisions, but we made the wrong ones and rue them much later in life. Then of course, there were indeed moments when we could not decide one way or the other and ended up as our own prince of Denmark.
All these were important moments in our own lives. What about our taking a decision that greatly influences someone else's life? Especially when it is a real matter of life and death? We are often called upon to decide admitting someone to a hospital for treatment. The issue may not be serious at that time and in our judgement only a matter of routine hospitalisation and being back home in a few days. Again, the decision to be made may be about a person to whom we are accountable or responsible for reason of being a blood relative or a close friend. It may also be a potentially serious and life threatening situation.
There are times when such decisions are to made when the patient in question is conscious and capable of taking decisions. It may also be cases where the patient is incapable of or unable to decide or understand the implication of the decision. Then there can be instances where the patient does not want to be hospitalised but there are good chances of recovery if done so. Various permutations and combinations throw their own possibilities, problems and "to be or not to be..." situations. "Who will foot the bill for expenses?" is another very important consideration, especially in cases where ours is more of a helping hand.
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The problems become even more acute after patient is admitted to the hospital. Complications may develop and now the issue is whether the patient should be moved to a ICU or not? Like the many avatars of Lord Vishnu, ICU also has many avatars. Intensive Care Unit (ICU), Critical Care Unit (CCU), Intensive and Critical Care Unit (ICCU), Intensive Therapy Unit (ITU) are some of the well known names, but there could be others as well. The ICU in a small hospital may not give the intensive care except for the fat bills, but in super speciality hospitals almost everything is available, except guarantee of retaining the life of the patient.
The climax of the "to be or not to be...." moments is reached when decision about placing the patient on ventilator is to be taken. The average cost of keeping a patient in ICU and ventilator support is upwards of USD 10,000 or equivalent per day in many hospitals abroad. Costs are very high in India as well. The costs are arrived by the hospitals after taking into account the cost of land and building for the room, capital cost of the equipments, clinical and non-clinical support costs, medicine and manpower costs etc. The fee for the team of experts is naturally expected to be high. The ICU professional team has many specialists like Cardiologist, Pulmonologist, Neurologist, Nephrologist and others depending on the type of care required. The last scene in this episode will be when a decision about taking the patient off from the ventilator is to be taken. Many families prefer Caesarean (C-section) deliveries so that they can fix an auspicious time for the birth of the child. in the case of taking off from the ventilator, it is often to decide when one should say goodbye to the patient.
There are complaints galore about hospitals moving patients to ICU and putting on ventilator support more for their reasons rather than patient's requirements. There are also complaints about patients being put on ventilator for extended periods when chances of recovery are non-existent. Most of the health care institutions follow ethical standards, but there are black sheep here too.
Overall, there are many serious issues about "To Be Or Not To Be in ICU".
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The wish of the patient is considered as paramount in some countries. There are legal provisions to appoint a person or persons to decide on such issues when the patient is unconscious or incapable of deciding for specific reasons. Many patients desire that they may be allowed to exit the world without the sufferings of the systems for higher health care.
It is in this background that Ministry of Health and Family Welfare, Government of India has now come out with "Guidelines for Intensive Care Unit Admission and Discharge Criteria" last week. It is a seven page document (actual content is only three pages) compiled in consultation with 24 experts in the field.
It lays down guidelines on the following aspects:
- What is an ICU and who is an Intensivist.
- Expert consesus statement giving
- ICU admission criteria
- Who should not be admitted to an ICU
- ICU discharge criteria
- Minimum patient monitoring while awaiting a bed in an ICU
- Minimum stabilisation required before admitting to an ICU
- Minimum monitoring required for Inter-facility transfer
The document is available at the following link:
It is advisable for all concerned to spend a few minutes and read the document to understand the issues involved. This will come in handy while taking a decision in "To be or not to be..." situations.
Interesting and relevant writeup. 🙏
ReplyDeleteVery very interesting article!
ReplyDeleteRelevant for us. Obe more decision is to be put in the geriatric ward. Patient and relatives have no choice.
ReplyDeleteVery information guiding spoke who cannot afford hop expenses versed their affection to gheersonin treatment wonderful articles indeed
ReplyDeleteAn interesting one-taking us back to our college days -studying English as if Shakespeare was our known friend, and at the end of our life, going to hospital as patient , thinking what is next, whether we we are shifted room/ward or to 3'x3' enclosure-to be or not to be.
ReplyDeleteAdmitting a patient in ICU is the norm in most of the corporate hospitals after ascertaining the availability of health insurance cover .
ReplyDeleteVery much informative and layer by layer narration is beautifully written.
ReplyDeleteExcellent writing and informative too
ReplyDeleteSir, to be or not to be…..is an eternal question we are faced with at almost all steps of life. Knowingly or unknowingly we take hundreds of decisions every day - some right and some not so right. Enjoyed the read. The guidelines issued are invaluable. Keep posting.
ReplyDeleteVery well written. This is a dilemma many of us have faced when wanting to take decision on our elders who are critical.
ReplyDeleteYou have touched on the issue which is haunting the minds of seniors like us. The tragedy is when a serious event like heart attack, brain hammerhoge happens, we will not be conscious for taking decisions. Sometimes I feel better to tell our caretakers that no major treatment shall be taken in such eventualities. Things should be left to God and kept in home. ICU also means the hospital telling the caretakers ‘I See You!’ LAKSHMINARAYANA K
ReplyDelete