Summary
Highlights
Dr. Kalantri begins by reflecting on how death, like birth, historically occurred at home. He recalls his mother's birth in 1926 and his own generation's home births. He notes a transition starting in the late 70s and early 80s, where death moved from homes to hospitals, and then increasingly into ICUs with advanced equipment. While acknowledging the life-saving impact of ICUs, he points out their gradual shift from acute life-threatening illnesses to managing chronic conditions, leading to unacceptable situations where patients with terminal illnesses die in ICUs.
The speaker delves into ancient texts like the Mahabharata, Jain mythology, the Quran, and the Bible, which present death not as a defeat but as a natural transition. He argues that modern medical training often treats death as a medical failure, a taboo topic. Doctors are taught to make diagnoses and intervene, but not how to discuss or accept death. This leads to an institutionalized denial of death, where medical records often state 'in spite of our best efforts, the patient could not be resuscitated,' implying failure. Junior doctors are often left to deliver bad news, facing angry relatives, perpetuating fear and anguish around death.
Dr. Kalantri observes that how one dies is often geographically and socioeconomically determined. The wealthy tend to die 'ugly, lonely technical deaths' in seven-star hospitals, intubated and isolated from loved ones. The middle class, with children often living abroad, experience similar lonely deaths while families micromanage care remotely. The socially marginalized and poor, suffering from chronic incurable diseases, are abandoned by medical institutions, left to struggle with symptoms and nowhere to go. He quotes Dr. Sanka, an oncologist, stating that the poor die in agony and neglect, the middle class in agony and ignorance, and the rich in agony on ventilators, none experiencing a peaceful, dignified death.
Inspired by Dr. M.R. Rajagopal, the father of palliative care in India, Dr. Kalantri established a palliative care unit in Sevagram. This unit admits patients with a range of terminal illnesses, not just cancer. Here, the approach is different: families are encouraged to stay, the environment is open, and there's a focus on comfort rather than aggressive intervention. Doctors in this unit 'do nothing' in terms of invasive procedures, instead sitting with patients, listening to their stories, and openly discussing death. Patients die peacefully, surrounded by loved ones, helping young resident doctors process their emotions and learn invaluable lessons beyond clinical science.
Dr. Kalantri illustrates the concept of a dignified death with the example of Vinoba Bhave, who, at 83, decided to stop all treatment, food, and water, choosing his own death. Despite concerns from medical staff and visits from then-Prime Minister Indira Gandhi, Bhave's decision was respected, and he died peacefully on Diwali in 1983. This is contrasted with a former Prime Minister who, at 93, after years of dementia, spent his final six weeks in an ICU undergoing every possible intervention, deprived of a peaceful death due to societal and political pressures. This highlights the irony that even powerful individuals are denied agency in their final moments.
Dr. Kalantri concludes by emphasizing the importance of individual choice in death. He discusses how the Indian Supreme Court has made living wills and advanced medical directives simpler, allowing individuals to specify their preferences for end-of-life care. He urges doctors to write their own living wills and educate patients and society about these directives. By doing so, doctors can overcome the fear of legal repercussions and offer patients dignified deaths, preventing countless individuals from undergoing 'ugly' and unwanted medical interventions. He highlights the success of the Kerala model, where terminal care is often provided at home by dedicated teams, a model Maharashtra should emulate.