Above: The time of death of former Tamil Nadu CM
J Jayalalithaa remains speculative. The funeral procession of J Jayalalithaa/Photo: UNI
A handful of VVIP deaths in recent times puts the focus back on the landmark judgment of the apex court last year where it held that the right to die with dignity is also a fundamental right
By Dr KK Aggarwal
We often see that politically sensitive deaths are put on hold until the security threat is over or to avoid violence and unrest. Sometimes, this is done to deal with the politics of succession.
According to a recent report in The Times of India, which later created a controversy, former Tamil Nadu CM J Jayalalithaa died on December 4, 2016, at 5.15 pm and not on December 5, when her death was announced to the public; this was done in view of security reasons. Similarly, a view abounds that former Prime Minister Indira Gandhi was taken to the All India Institute of Medical Sciences (AIIMS) in New Delhi at 9:30 am on October 31, 1984, after she was shot by her own security guards, but fearing violence, it was only late in the evening that she was declared dead. Very recently, speculation raged over whether the chief minister of a western state, although clinically dead, was being kept alive with some specific purpose in mind. Maharaj Ashutosh’s frozen body has been kept for the last five years on the grounds that he is in samadhi and will come back to life.
Doctors face such situations occasionally. The medical question thus arises: Can death be postponed scientifically? There can be two situations, delaying the declaration of death or delaying the process of death. In the first case, a dead person is kept on a ventilator till the death can be announced. The second situation is encountered in intensive care units (ICUs), where doctors often delay the process of death by way of interventions, which otherwise are not going to help. Often, the request comes from relatives living outside the country.
Medically, we know that natural death is an active process and not instantaneous, unlike unnatural deaths. So, it is possible to halt the process at any stage by giving heavy sedation, anaesthesia, keeping the body on a ventilator or in a state of therapeutic hypothermia.
But can we play with the life of a dying person? A dying person also has legal rights. In the 2018 case of Common Cause vs Union of India, the SC held that the right to life and liberty, as envisaged under Article 21 of the Constitution, is meaningless unless it encompasses within its sphere individual dignity. The right to live with dignity also includes the smoothening of the process of dying in case of a terminally ill patient or a person in persistent vegetative state with no hope of recovery.
In this case, the constitution bench specifically held that the decision by a treating doctor to withhold or withdraw medical intervention in the case of a patient in the terminal stage of illness or in a persistently vegetative state or the like, where artificial intervention will merely prolong the suffering and agony of the patient, is protected by law. Where the doctor has acted in such a case in the best interests of the patient and in bona fide discharge of his duty of care, the law will protect the reasonable exercise of a professional decision.
Further, in the said case, the SC settled the law with respect to euthanasia. It observed that there is an inherent difference between active euthanasia and passive euthanasia as the former entails a positive affirmative act, while the latter relates to withdrawal of life support measures or withholding of medical treatment meant for artificially prolonging life. In active euthanasia, a specific overt act is done to end the patient’s life whereas in passive euthanasia, something is not done which is necessary for preserving a patient’s life. It is due to this difference that most countries have legalised passive euthanasia either by legislation or by judicial interpretation with certain conditions and safeguards.
Vedic sciences recognise that death is not instantaneous but is a process, and we must recognise and respect that process. As per the Upanishads (Prashnopanishad and Chandogya Upanishad), the first to go are the karmendriyas (the last to go is speech or Vak Vriti), then the gnanendriyas (the last to go is hearing, mind, intellect, ego and memory or Mano Vriti) followed by prana (Prana Vriti). The last to go is the metabolism (tejas), which merges with the Sat or consciousness.
At every stage, the process may be reversible or irreversible, which should help decide whether to continue with life support or not. If the clinical situation is irreversible, it is better not to postpone death. Till there is breath in the body, one can halt the process by artificial ventilation, and till the metabolism is functional, one can halt the process by artificial hypothermia. It is possible to preserve the last breath or heart beat by freezing the body and, years later, by warming the body and doing effective CPR, it is possible to reproduce the pre-frozen state. We do it every day when we freeze sperms, ova, organs and cells.
Way back in 1969, Elizabeth Kubler-Ross, a pioneer in the field of near-death studies, identified the five stages of grief for the imminent loss of one’s life—denial, anger, bargaining, depression and acceptance. In the first two phases, the patient is often confused, and in the absence of spiritual chaplains to counsel him or her, the easiest way for the doctors is to postpone death till a family member starts accepting the facts.
Ayurveda “recognises that each person is made up of a unique body type and psychological personality”. Vata dosha represents the forces of movement; pita the metabolism; and kapha the structure. Vata imbalance needs a lot of handholding, support, calming therapies, nurturing and a deep sense of connection with others to heal. Vata governs depletion, destruction, decay, necrosis, debility, dissolution, and the process of wasting away and shutting down. Signs of impending death such as change in smell, bodily organs shutting down, core temperature instability, gurgling breathing (death rattle) and mottling of the skin are all vata symptoms. Terminal agitation, a dying patient’s behaviour of responding unpredictably, is also linked to vata.
Pitta individuals can be over-controlling and demanding. They and/or their family members are very direct and intense, and communicate in an explosive way due to their feelings of helplessness. Strategies to support pitta patients and families in the dying process include cooling, relaxing and stress-diffusing forms of aromatherapy, breathing practices, yoga nidra and guided meditation.
Imbalanced kapha manifests as stubbornness, lethargy, withdrawal, depression, and issues of attachment and possessiveness. Kapha individuals are slow to change, but once change is implemented, they are steady and enduring in new habits. When working with them in the dying journey, it’s important to understand that they may experience a longer grieving process. Kapha individuals can also internalise emotions and not show them, even though they feel very deeply. Honouring relationships is crucial, as is self-care for caregivers and families who have deep attachments to individuals who have passed on.
—The author is President, Heart Care Foundation of India, and President-elect, Confederation of Medical Association of Asia and Oceania