The right to live (and die): an overview
Care of the terminally ill patient and professional 
responsibility are the moot points
By Dr R.P. Sapru
The care of the terminally ill patient is always a harsh and emotive experience. There cannot be any single pre-determined approach to such a situation since real life scenarios vary over a very wide spectrum. On the one end are patients suffering from diseases like cancer, AIDS or chronic renal failure for which no cure is in sight.

Does your child wear glasses?
By Dr Kanwar Mohan
Normally, when we look at an object, the light reflected from it enters the eye and is focused into a clear image on the retina (the inner sensitive layer of the eye). The retina then sends signals to the brain which interprets this image and we are able to see. The failure of light to focus on the retina leads to blurred vision, a condition known as "refractive errors". 

Gloom at sunset
By Dr Rajeev Gupta
Depression, a bane of maddening urbanisation, is hitting old people hard in our country. Gone are the days when the elderly were given genuine respect and regards by the members of their families. In fact, they were kept on a high pedestal in society. Their wisdom and experience were highly valued.

The right to live (and die): an overview
Care of the terminally ill patient and professional 
responsibility are the moot points
By Dr R.P. Sapru

The care of the terminally ill patient is always a harsh and emotive experience. There cannot be any single pre-determined approach to such a situation since real life scenarios vary over a very wide spectrum. On the one end are patients suffering from diseases like cancer, AIDS or chronic renal failure for which no cure is in sight. These patients are fully conscious, alert and able to look after themselves. On the other end are the patients whose life is maintained only with the help of artificial life support systems with little hope of recovery. There is a very large number of patients whose situation would fall anywhere in between. In the first instance, the patient is fully capable of taking decisions for himself and indeed does so. Most, if not all, such patients usually have a strong will to live and are prepared to undergo any form of treatment, including surgeries. This attitude is not related to the level of education or information available with the patient.

Psychologists believe that these patients often shut out their mind to honest professional medical opinion that their illness is incurable and that the end is near. The basic human instinct that "even though death is a certainty it is not going to happen to me; not yet anyway" takes over. The patients, therefore, submit to treatment however painful or disagreeable.

The opinion of care-givers is irrelevant in this situation except in so far as that impinges upon the financial resources required for the treatment of the patient. However, the attitude of the care-givers does substantially influence the quality of life of the patient as well as the will to fight the illness.

On the other hand, when the patient is physically handicapped or mentally clouded, the role of the care-givers assumes greater significance, especially in our society where institutional care for such patients is still in its infancy or practically non-existent. As in any walk of life, the attitude of care-givers does differ widely. Some are very supportive of the needs and comforts of their wards and others who would literally give anything to see the back of the patient.

The duty of the attending doctor is clear: provide all means to prevent death, to prolong life and to alleviate pain and suffering. Withholding treatment even under pressure from the care-givers is not an option open to the doctor. Of course, an occasional patient may, by choice, opt out of the prescribed treatment or choose to follow some other claims to therapy. That is the patient's inalienable right. In such a case the doctor is duty bound not to force his attention on the patient either by withholding adverse information or by misleading the patient. Only persuasion using full disclosure of facts and education of the patient and the care-givers would be permissible, nothing else.

At the other extreme is the unconscious patient who is in no position to express an opinion about his own care. Therefore, all decisions have to be taken on his behalf by the care-givers, especially the legal heirs, and the attending doctors.

Here again the care-givers are known to hold any number of shades of opinion between two extreme views: one that would suggest that the life support systems should be withdrawn since the chances of recovery are slim, the cost of management high, the dignity of the patient compromised and the care-givers under excessive strain. Yet others would insist that efforts at preserving life be continued as long as there is some hope of survival.

Amongst the various concerns usually expressed by the care-givers in this connection are the pain and suffering of the patient, a perceived compromise in the dignity of the patient, of the value of life and of the cost-effectiveness of treatment. For clarity of thought it is necessary to examine these statements dispassionately.

As far as pain and suffering are concerned, the unconscious patient is beyond such feelings! The pain and suffering are a projection by the care-givers of their own reactions to what they see; it has nothing to do with the factual position as experienced by the patient. Human beings often use this kind of response in a variety of life situations. The same applies to the question of the "dignity of the patient". Often it is dignity as perceived by the care-givers that is felt to have been compromised. In this connection it is important to recognise that the care-givers are often under a severe physical, emotional and financial strain, especially if the care is prolonged. It is not uncommon under the circumstances for the care-givers to portray their own difficulties as reflective of concern for the patient.

The value of life is difficult to judge. All handicapped persons, who are dependent for care and support, are technically a liability on the care-givers in particular and society in general. The value of such lives is not in the intrinsic worth of the individual measured in terms of "return on investment", but in the importance that the care-giver gives to such persons as well as the social value system of the time. There are any number of examples of people, especially mothers, having devoted their lives to the care of their handicapped wards. The same applies to the terminally ill patients. Such care-givers are known to derive satisfaction and pleasure from having made their wards the focus of their lives. Examples of this kind abound particularly in societies where the value system is less materialistic and more supportive of spiritual pleasures.

The role of the doctor in this scenario has been a subject of debate. This matter has been sorted out to a great extent by the laying down of definite criteria that indicate when a person is brain dead. In medical parlance, the recovery of a person is not possible once the brain is dead. In all other circumstances, it is the duty of the doctor to persist with efforts to preserve life as far as possible. As has been wisely said, a doctor should not "play God".

Euthanasia is a subject of great debate and is as yet unaccepted by medical practice. It impinges on unsolved emotive issues. If euthanasia is acceptable, why not suicide? The patient in either instance desires to end his life! So it could be argued.

The question of the "cost-effectiveness" of treatment is somewhat related to the question of the "value of life". It is often argued that in a cash-starved economy the best use of the limited resources should be in areas that would provide the maximum benefit to the largest numbers. That argument is music to the ears of hard-boiled businessmen but in the process misses out on humanity. Consider a scenario on the battlefront. Should a critically wounded soldier be left to perish just because his chances of survival are slim or evacuation is likely to slow the advance or retreat of other soldiers, whatever the case may be? There would be few takers for that argument. So why pick out on the weak and the sick who are in no position to argue for themselves?

Thus issues related to the care of the terminally ill patient are more complex than they appear on the surface. It is important to view these dispassionately and avoid the mistake of projecting the feelings, experiences and thoughts of the care-givers as though these are reflective of the opinion or feelings of the patient especially when the latter is in no position to express or even formulate an opinion. Efforts of the doctor to persist with all possible measures to preserve life, prevent pain and suffering and promote health in spite of all odds are reflective of his professional responsibility and not a measure of lack of sensitivity. For the doctor the primary responsibility must be the patient, not the care-giver. The inability of the doctor to agree with the assessment and perceptions of the care-giver is not insensitivity but a dispassionate awareness of professional responsibility.

There is universal concern that adequate safeguards must be applied for the control of weapons of mass destruction or of human experimentation or of scientific research, such as cloning, that has the potential for creating a social upheaval. The question of letting doctors "play God" and decide when any life, however, "useless", may be extinguished, no matter how passionately the patient or the care-givers feel about it, is in the same class, or else hell will be let loose.

Dr Sapru, the former head of the Department of Cardiology at the PGI, Chandigarh, has participated in many international debates on ethical issues abroad and on the Internet. All correspondence or communication regarding this article should be directed to the author at 1112, Sector 7, Panchkula, Haryana (Ph: 582801, 582802). 

Does your child wear glasses?
By Dr Kanwar Mohan

Normally, when we look at an object, the light reflected from it enters the eye and is focused into a clear image on the retina (the inner sensitive layer of the eye). The retina then sends signals to the brain which interprets this image and we are able to see. The failure of light to focus on the retina leads to blurred vision, a condition known as "refractive errors". There are three types of refractive errors. If the rays of light focus in front of the retina, the situation leads to near-sightedness (myopia) and if they focus behind the retina, far-sightedness (hypermetropia) is caused. If the rays of light focus at more than one point, a single clear image cannot be formed on the retina and it is called astigmatism.

Refractive errors commonly occur due to a lack of proportion between the increase in the size of the eye and its focusing power. Therefore, they manifest when a child is growing. In myopia, the eye is longer than its focusing power. So, the rays of light focus in front of the retina, whereas in hypermetropia, the eye is shorter than its focusing power; the rays of light focus behind the retina. Astigmatism occurs when the surface of the cornea (the front transparent part of the eye) is distorted causing a change in its curvature; the rays of light focus at more than one point on the retina and cause blurred vision.

The poor vision due to refractive errors is commonly corrected by glasses or contact lenses and now by LASIK laser also in selected cases. As contact lens fitting is difficult in children and LASIK laser is not advocated until a person — is about 20 years of age, glasses are the only method available for correcting refractive errors in children.

The refractive errors are accurately diagnosed by a simple procedure of refraction done manually or by computerised auto-refractometer. For the accurate assessment of number, the involuntary muscles of focusing, inside the eye, should be completely relaxed. An adult can relax these muscles but a child cannot. Therefore, to detect an accurate number (power) of glasses, we need to paralyse the focusing muscles with medicine. The Atropine eye ointment, a stronger medicine, is used in younger children with very strong focusing effort, whereas the cyclopentolate eye drops, a milder and short-acting medicine, may be used in older children with a less strong focusing effort. (Please make sure that the doctor has instilled these medicines into your child's eyes before checking for the power for glasses!)

With the doctor's prescription in hand and your anxious queries answered, the next step is to go to an optician to make glasses and to select a suitable frame and appropriate lenses for the spectacles. The spectacle frame must be rigid, strong and light. It must fit securely, yet lightly and easily, causing no irritation to the parts of the skin where it touches and rests.

The frame should hold both the lenses firmly and constantly. The lenses are placed as close to the eyes as the lashes permit, usually at 12-14 mm from the front of the eye. If the frame is loosely fit, the glasses tend to slip forward and this causes a change in the effective power of the lenses.

The effective power of a plus lens increases and that of a minus lens decreases as it is moved away from the eye. Therefore, the spectacle frame should not be loose and should always rest at the same place about 13 mm from the cornea or just near the eye lashes.

The use of an elastic strap provides an effective means of fixation of spectacles in children. It is advisable to have a plastic frame as it is light and firm, and cannot be bent easily. Frames with attractive colours are easily accepted by children. So let your child select the colour of the frame of his/her choice.

Children should have spectacle lenses made of plastic instead of glass. A glass lens breaks easily if a child falls and the glass splinters can injure the eye. The plastic lenses are light and unbreakable. Therefore, an added advantage is gained when high-power lenses are required. Also a plastic lens does not fog up so quickly as a glass lens in changing temperatures (going out of an airconditioned room in the rainy season) because it cools slowly. In children especially, large glasses providing a full-field are best. With them, they do not attempt to look over the glasses.

When the child starts wearing glasses for the first time, some symptoms like tightness on the sides of the head, heaviness of the eyes, etc, are not unusual. These symptoms are usually short-lived and most of the children tolerate glasses very well after a few days. If intolerance to glasses persists beyond a few weeks, consult your doctor. Do not discourage the child. Do not give the idea that the glasses are for a short time and will be removed shortly. Prepare him or her to accept glasses as a part of the normal dress. Make the child feel proud of glasses and not ashamed of them. Do not let the child develop inferiority complex. There is also the need to prevent relatives/friends from making comments about the child.

The use of glasses affects eye muscles balance. Therefore, get the eye muscles balance checked by the doctor if the child feels some strain with glasses. An allergic reaction to the material of glasses at the points where the frame touches the skin is very rare. Intolerance to glasses may also be due to constant irritation when a newly acquired spectacle frame bears heavily on the skin or when the surface of old spectacles has become dirty and rough or has been covered with other material. A change in the spectacle frame or its material solves this problem.

You should check the lenses and the side bars of the glasses regularly to ensure that the lenses are clean and scratch-free, and the side bars are not bent.

(To be concluded)

Dr Kanwar Mohan is the chief of the Squint Clinic at the Grewal Eye Institute, Chandigarh.

Gloom at sunset
By Dr Rajeev Gupta

Depression, a bane of maddening urbanisation, is hitting old people hard in our country. Gone are the days when the elderly were given genuine respect and regards by the members of their families. In fact, they were kept on a high pedestal in society. Their wisdom and experience were highly valued.

Now, many elderly persons consider themselves just as junk or completely unwanted beings in the "rapidly progressing" society. The number of such persons as have crossed the age of productivity is swelling fast. The increasing facial wrinkles, proportionate to the number of pathological worries and mental preoccupations, are becoming the identification mark of the senior citizens.

Visit any park in the evening and you will find dozens of ageing people sitting there, pathetically killing time. They have been forced to spend their waking hours outside their homes and a good number of them have horrifying tales of neglect to tell.

The increasing life-span has added to their woes. The shift from the joint family norm to the nuclear family status has callously banished seniority as a criterion of respect, power and dignity from nuclear households, leaving the elderly in the wilderness of a value-free society. The fast psycho-social changes sweeping the globe have affected them adversely.

The feelings of loneliness and loss of status along with the sense of neglect are driving more and more people to despair. Psychological, physical and social reasons have been attributed to the rising old-age depression.

Following retirement, many persons plunge into severe gloom. The condition is caused by social and financial factors which lead to emptiness and purposelessness in life. Many retired men and women fail to adjust themselves to a vacuous vagary. They feel that retirement has led to a demeaning position at home too. Those who were egotistical and authoritarian in their jobs, find that their temperamental traits have no acceptance in their families.

Similarly, depression is experienced by the elderly after the death of the spouse. Scientific studies have established that the death of the "supporter" is an important cause of depression.

In cities, the number of old couples staying away from their children is going up. The situation is better in business families where financial controls continue to remain in the hands of the senior members who are not willing to pass on their power and authority to their children. The grown-up children continue to look forward to the elders for their needs. They are in no position to annoy or offend their parents. Even highly educated and "modern" daughters-in-law are courteous to them.

On the contrary, the children of professionals and other regular employees become independent and have the privilege of maintaining separate households. This group is becoming a victim of isolation.

Quite often, the elderly become natural victims of age-related problems like cataract, bone and joint ailments, prostate diseases, anaemia, osteoporosis and cardiovascular maladies.

Illness means a substantial financial burden, which many families are not in a position to bear. In the absence of adequate medical care, health-related problems become constant sources of mental and physical trauma. Many drugs predispose a person to depression. Physical disabilities too become a cause of depression.

Common symptoms: Sadness, weeping spells, sleep disturbances, the loss of appetite, the loss of weight, poor bowel functioning, negative thinking, suspiciousness, the lack of trust, the fear that others may harm them and suicidal ideas are the common symptoms in depressed old persons. Some patients are "convinced" that their intestines and food pipe are blocked and nothing can pass through them. Auditory hallucinations are also experienced by a few of them. Under the effect of a severe low feeling, some patients commit suicide. A number of depressives also show aggressive behaviour.

Management: Psycho-social support is the main anchor of treatment in such cases. A sense of security helps the mentally ill to come out of the dark phase. The feeling that they can depend on their family members and friends helps them in being comfortable.

Antidepressant drugs meant to correct the biochemical imbalances in the brain are helpful in 70-80 per cent of the cases. The dose of these drugs is smaller for them than that for adults.

Drugs like imiprimine (Depsonil) and amitriptyline (amitryn), which are most frequently used for the adult depressed patients have more side-effects in the elderly. Fluoxetine (Nuzac, Fludac) and sertraline (Serlift, Sertima) remain the drugs of choice. For a single depressive episode, drug treatment is recommended for four to six months.

For those who get repeated episodes of depression, doctors can think of lithium therapy. It is mandatory to assess the cardiac and renal functions of the patient before starting lithium (Lithosun, Licab) treatment. Those on lithium have to be periodically assessed for serum lithium levels. Electric treatment is kept as the last refuge in the elderly depressives. This treatment is given under strict medical supervision when patients have a high suicide risk and fail to respond to medical and psychological treatment.

It is important to remember that psychiatrists, psychologists or counsellors can not help such depressed persons unless they are able to get adequate psycho-social support from society and families.

Dr Gupta is a Ludhiana-based psychiatrist and the author of helpful books on depression in modern life in English, Hindi and Punjabi. The specialist also acts against mental diseases through his journal (Meditrack) and an Internet website.