BMJ  2004;328:1385 (5 June), doi:10.1136/bmj.328.7452.1385

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PERSONAL VIEW

If it was your brother

"Doctor, do what you would do if it was your father or brother," requested the son of a patient who had been given a diagnosis of cancer of the pancreas with liver metastases. The patient's condition rapidly deteriorated that week, and I had a meeting with the relatives to update them and also to prepare them for the worst. But the son's request made me feel uneasy and set me thinking about events in my own family.

Two years ago I went to India to arrange medical care for my eldest brother, who was given a diagnosis of carcinoma of the tongue six years previously. Unfortunately radiotherapy had resulted in severe side effects. He had dysphagia, had become very thin, and had to be fed through a gastric tube. He had been experiencing severe pain in his throat and ear. In addition he developed lung cancer, though he seemed to have responded well to chemotherapy.

That year had been a very difficult year for him—and also for me trying to care for him from 7000 kilometres away. He used to email me everyday, describing all his symptoms, and I would reply to him after I came home from my work. Medical books and teachers certainly helped me to become a medical scientist, but he inspired me to be a doctor in the best sense of the word.

I learnt a great deal of medical ethics from my medical training, but the essence of medical ethics I learnt from this brother. When I was a medical student he used to talk about the difficulty of understanding what pain, whether physical or emotional, is in medical as well as philosophical terms. Was he a neurologist, an anaesthetist, or a psychologist? None of them. He was a civil engineer. I learnt that to understand the patient's feelings better I needed to take off my doctor's hat sometimes and put the layman's hat on.

So there I was with him in India faced with two challenges. One was a therapeutic challenge: pain relief. The second challenge was to find a doctor with a special interest in pain management in the commercially driven world of medicine in India. I talked to my brother about pain management plans for him and also various family matters. It was around midnight when he bade us goodnight and went to the toilet. Two or three minutes later we heard him clapping, which he would do if he needed attention after he lost his voice from the radiotherapy. As I was getting up from the bed he opened the toilet door, and there he was looking very frightened with blood gushing out from his nose and mouth in a projectile manner. The floor and walls were covered with blood. I rushed to hold him. I knew he was going to collapse in the next couple of seconds, not minutes. As I and the others helped him on to the floor he There lost consciousness. was panic all around—relatives were screaming and crying in shock and calling his name in the hope of bringing him back to consciousness.

There I was with my beloved brother in my hands, and I was losing him very fast in front of my own eyes. I started cardiopulmonary resuscitation, and then my son joined me in the resuscitation. He had just then finished his preregistration house officer stage, so he was better at it than I was. After 15 minutes or so of resuscitation there was no spontaneous breathing and no cardiac output. Shocked and panicked my relatives may have been, but they were probably still hoping that my son and I would succeed in our resuscitation. The ambulance arrived, though without oxygen, any resuscitation equipment, or any paramedics. So it was basically a van with a driver. My relatives insisted that we should get him to a hospital. Then it dawned on me. I came to my senses and realised that I should act as a doctor, not as a brother. I stopped everything, asked my son to stop resuscitation, and indicated to my relatives that my eldest brother was no longer with us.

Inappropriate cardiopulmonary resuscitation? Yes, when I look back on the events I realise it was, but my strong love and emotional attachment to him caused a momentary lapse in my clinical decision making. So, when my patient's son asked me to treat his father as if he were my father or my brother, I knew that what I would have done would be the wrong intervention. But would he have known this? Of course he wouldn't have.

the Royal London Hospital, London drmacherla{at}yahoo.co.uk

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