For healthcare professionals only


Don't give up hope

BMJ 2005; 331 doi: (Published 21 July 2005) Cite this as: BMJ 2005;331:207
  1. Kaushal Raj Pandey, medical student (krpandey702{at}
  1. Institute of Medicine, Kathmandu, Nepal

    In a recent visit to the intensive care unit I saw a 69 year old Hindu patient. His case was unusual in that he had been brought back to our hospital after active treatment had been declined by his family at an earlier presentation.

    He had first visited the hospital 25 days previously for limb weakness and bladder and bowel incontinence associated with dizziness but no headache. He had no spinal injury, and the results from magnetic resonance imaging were normal. He was sent back home with conservative management—corticosteroid, multivitamins, and treatment for his concurrent illnesses of benign enlargement of the prostate and hypertension.

    The patient then developed acute retention of urine, for which he was taken to another hospital and catheterised. He was admitted for 10 days, and during that time he developed absolute constipation, which was relieved with an enema. He was discharged back home.

    At home he developed abdominal pain and distension, constipation, and reduced urine output, and was brought back to our hospital. His general condition was poor, and a provisional diagnosis of peritonitis secondary to bowel perforation was made. This was explained to his family, who were asked for permission to undertake a diagnostic laparotomy. The family, however, refused: they thought that he was approaching death and that he wouldn't benefit from further active treatment. Instead, they wanted to allow him to die at Pashupatinath temple. The doctors therefore simply inserted two abdominal drains under local anaesthetic, and about 50 ml of fluid drained from each.

    The patient was duly taken to Pashupatinath to await death in the vicinity of the great Hindu god Pashupati. During their wait, the family members felt that the patient showed some improvement and so brought him back to our hospital. This time they gave the high risk consent for emergency laparotomy. This revealed multiple jejunal diverticula and a large perforation in one of them. After resection and anastomosis, the patient's condition rapidly improved.

    Many Hindus believe that dying at a holy site will secure a place in heaven, and strive to achieve this. However, this can create a dilemma as to when to go to the temple or shrine of choice, where there are unlikely to be any treatment facilities. It is very difficult for family members to make such a decision for a patient who is elderly with multiple illnesses. In my opinion, however, the question of when to die should be more important than choosing where to die. We should obviously respect patients' wishes, but it is equally important to teach them that they should give treatment a chance first. “Saas rahe samma aas” [Hope till the last breath] as a motivational Nepali proverb says.

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