Friday, July 6, 2018

Burari suicides: Was it a case of mass suicide or an induced psychotic disorder?




Dr K K Aggarwal
Padma Shri Awardee
President Heart Care Foundation of India


Ever since the Burari deaths were reported, it has set us all thinking and trying to find answers about what might have happened, what were the preceding events that made the entire family commit such an act? I too have been trying to understand the reason behind these mass deaths.

Mass suicides may occur for a number of reasons. People can be brainwashed to commit mass suicides. In such cases, the mind is in an extremely parasympathetic or relaxed state of mind and so becomes a suggestive mind, one which is more receptive to accept and act on the suggestions of others. A person who is in an emotional state of mind tends to be more receptive to ideas and suggestions of others and is therefore more suggestible.

The sympathetic state is the ‘fight or flight’ response of the body which comes into action when the body perceives a threat. In a sympathetic state of mind, a person would fight off suggestions through the processes of conscious defenses and critical judgments.

Suicide bombers or suicide attacks are another category of mass suicides, where the motivation may be an ideological cause or nationalism like the kamikaze, who carried out suicide aerial missions for Japan against allied forces in World War II. Mass suicides may be a means to focus attention on a particular issue. Mass suicides by farmers may be prompted by reasons such as persistent droughts, or damage to crops due to floods or any other cause. Jauhar or the custom of mass self-immolation, which was historically practiced is well known to us all.

But none of these applied to the family in Burari. So what led to this family of 11 to carry out such an act?

When I spoke to Dr Sanjay Chugh, a well-known neuropsychiatrist in Delhi, he said this could be a case of induced psychotic disorder or shared psychotic disorder, where one psychotic person in the family can induce one or more members of the family into a psychotic behavior. Typically, this disorder is characterized by transmission of delusions from the inducer, who is the originally ill patient and suffers from a psychotic disorder, to another person who may share the inducer's delusions in entirety or in part (J Res Med Sci. 2011 Mar; 16(Suppl1): S453–S45). 

This disorder is usually common among people who live in close proximity and in close relationships. When one person is induced it is called Folie e deux; when it induces two, it is called Folie e trois; folie à quatre, when three people are induced, folie à cinq, when four are induced. Rarely, when all the family members share the same delusions, this is called folie à famille.

In such cases, dynamics of the family also play a major role. There are families that blindly worship the patriarch and would obey his commands without questioning his authority.

It appears from reports that in this case, Lalit probably had a psychotic disorder, who over a period of time induced others in a psychotic behavior, which ended in a mass suicide-like action. He thought he was conversing with his dead father and convinced his family that he was possessed by his father’s soul and hence was soon accepted as the head of the family as reported.

There are also reports that Lalit was particularly attracted to tantric beliefs. It all began with some ailment that his own son had, because of which he had lost his voice few years back. His voice was restored after Lalit is said to have performed some kind of tantric sacrifice, which may have reaffirmed his belief in such practices.

It has also emerged that the family was under influence of a self-styled tantric known as Gada Baba, who practiced some banyan tree occult. It has references saying that the dead bodies should replicate the prop roots of a banyan tree. The handwritten notes in the diaries found, call this as “badh or vat tapasya” saying that doing this would “make God happy”. This is also how ten of the 11 dead bodies were found hanging from an iron mesh in the house, in a formation resembling the hanging roots of a banyan tree.

The Banyan tree is associated with Yama, the God of death. The Banyan tree does not allow grass to grow under it indicating that it does not allow for any rebirth and renewal. A banyan tree is said to be immortal. It is stable and constant.

This family might have carried out the Banyan tree ritual harboring a false but firm belief that they too will not die. They were convinced by Lalit that their father’ soul would appear and save them after the ritual.

CCTV footages have shown five stools being carried into the house that would be used for the hanging, but 11 people died. This is indicative of one person who ‘masterminded’ or planned and directed the entire ritual. Incidentally, the postmortem report indicates that Lalit and his wife were the last to die.

This story needed to be told here to create awareness about induced psychotic disorder, which is reportedly a rare disorder. It is important to remember that one psychotic patient can influence others in their vicinity. Physical separation of the inductor and the recipient/s, who do not have a mental illness in such cases, may prevent sharing of delusions. The inductor often may be suffering from schizophrenia.



Dr KK Aggarwal
Padma Shri AwardeeVice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA



Thursday, July 5, 2018

Understanding the importance of Agni



    
In Hinduism, Agni or fire is worshiped in all rituals like havans, yagnas, ahutis, sankalp or seven pheras of walking around the sacred fire in any wedding.

    
Externally the fire burns and converts any matter into an ash or bhasma. Ash is the essence, purest form and once formed contains no trace of original matter.

Internally, Agni symbolizes burning of all negative desires, expectations, ego and anger in the fire of knowledge by surrendering ego and egocentric desires into the fire of knowledge or spontaneously let it burn in meditation. The result is a pure mind devoid of negative thoughts and desires. Only a purified mind is able to meditate because while prayer is talking to God, meditation is listening to God. Meditation is the path to self-realization and controlling anger, greed and other negative tendencies.

    
In the Kathopanishad, in a conversation, Yama taught the importance of internal fire or internal churning and called it Nicheketa fire.


The internal Yagna thus is the churning of any information in the fire of knowledge and converting it to wisdom. Adopt the essence and implement it in day to day life to achieve self-realization. Once knowledge has been converted into wisdom it is of no use unless it is made use of in day to day practice.

Burning of all our thoughts, desires and expectations in the fire of knowledge or agni and accepting the resultant ash is the mantra.

Dr KK Aggarwal
Padma Shri AwardeeVice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA



Wednesday, July 4, 2018

Should organ donation be incentivized?




The govt. is considering giving financial incentives to persons and/or their families who donate their organs. The Union health ministry has recommended that state health departments offer ‘cash rewards’ for organ donation. As per the recommendations and as per TOI reports, the donor’s family may get anything between Rs 1 lakh–Rs 5 lakh per year for five years and the organ retrieving hospital will get Rs 50,000.

Deceased organ donation is the main source of organs, but it requires informed consent of the family or the legal heir. Live organ donation is also an option in some cases.

Organ donation has so far been voluntary. It is a truly altruistic gesture, one which also indicates the tremendous courage of the family, which makes this selfless decision in their time of immense grief. While there is a long list of patients waiting for an organ, the number of available organs is too few to meet the requirement. So, could this step be an attempt to bridge this huge gap?

Being a govt. policy, may be considered ok, but only for cadaveric donation and as long as the policy is uniform and does not promote organ trade, which should be of great concern given the social inequalities in the country and the tremendous divide between the rich and poor, which provide ample opportunities for organ trade. Therefore, there should be no direct communication between the donor and the recipient family.

In its “Guiding Principles on Human Cell, Tissue and Organ Transplantation”, the World Health Organization (WHO) in the commentary on Principle 5, notes, “Payment for cells, tissues and organs is likely to take unfair advantage of the poorest and most vulnerable groups, undermines altruistic donation, and leads to profiteering and human trafficking. Such payment conveys the idea that some persons lack dignity, that they are mere objects to be used by others… National law should ensure that any gifts or rewards are not, in fact, disguised forms of payment for donated cells, tissues or organs. Incentives in the form of ‘rewards’ with monetary value that can be transferred to third parties are not different from monetary payment.”

In my opinion, if the govt. wants to offer incentives to encourage voluntary organ donation, it can look for non-monetary options. The govt. can recognize and honor those people who have donated their organs after death and their families by according them a national honor. Or, they could be given benefits and facilities similar to those given by the Govt. to the Freedom Fighters. Else, they could be given insurance benefits under Ayushman Bharat National Health Protection Scheme or education for the children of the family can be funded through scholarships or they can be given free train tickets etc. And, if by any chance, they happen to require organ donation themselves, they should be given priority.

Dr KK Aggarwal
Padma Shri AwardeeVice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA



Tuesday, July 3, 2018

Thank you all for the honor on Doctor’s Day




On Doctor’s Day this year, Delhi Medical Association bestowed upon me the ‘DMA Medical Excellence Award’. I was also awarded by The Economic Times at the Economic Times Doctor’s Day Conclave on 30th June for creating a difference in the healthcare sector. ET also identified me as a ‘Doctor with the stethoscope’ in their book on ‘Inspiring Cardiologists of India’.

I have often been asked why I always wear a stethoscope. Wearing a stethoscope is a constant reminder of my medical ‘dharma’ or purpose, which is to abide by the principles of beneficence and non-maleficence at all times and to be available to my patients always. This is why we chose to become doctors - to treat our patients, alleviate their sufferings and try to save their lives to the best of our capabilities.

Doctor’s Day is a reminder to me that being a doctor makes me different. As doctors, we have the privilege of writing ‘Dr’ before our names. Doing so is not to confer status upon us, it means to be available 24x7 for our patients and ready to help in all emergencies unconditionally.

I am deeply honored to receive these awards and acknowledgements.

We may have received several awards, but receiving an award from the Association always means so much more since it is symbolizes the recognition of our achievements by our colleagues.

I express my thanks to you all, dear friends & colleagues, but most of all, I thank my patients for having trusted me to take care of their health needs.


Dr KK Aggarwal
Padma Shri AwardeeVice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA


Monday, July 2, 2018

Landmark judgements that have changed the practice of medicine




Practicing medicine has become very challenging today; more so because the doctor is now required to be equally well-versed in legal aspects as much as he is expected to be proficient in his clinical knowledge.

The concept of informed consent has undergone a radical change over the years. Informed consent has now become an absolute legal necessity and it is the only safeguard available to the doctor as protection from malpractice claims. Unprecedented compensations amounting to more than one crore have been awarded.

In its judgment in “Dr. Balram Prasad versus Dr. Kunal Saha & Others”, the Hon’ble Supreme Court of India awarded a compensation of Rs. 6.08 crores to Dr Kunal Saha. After addition of interest, this figure increased to Rs. 11 crores. Rs one crore each was also awarded as compensation in the judgements in Nizam Institute of Medical Sciences vs Prasanth S Dhananka and Ors and Dr. (Mrs.) Indu Sharma vs Indraprastha Apollo Hospital, April 2015. The result is a huge increase in the number of cases filed against doctors; unfortunately, many of these are on frivolous grounds.

Then there have been four landmark judgements on informed consent, delivered not only by the highest court of India but also the highest foreign courts. 

All these judgments should be read by all doctors.

A doctor cannot delegate the duty of taking informed consent to his junior staff. Last year, the Supreme Court of Pennsylvania in Shinal vs Toms162 A.3d 429 (Pa. 2017) has held that “the duty to obtain informed consent belongs solely to the physician and that it is non-delegable… a physician may not delegate to others his or her obligation to provide sufficient information in order to obtain a patient's informed consent. Informed consent requires direct communication between physician and patient, and contemplates a back -and -forth, face-to-face exchange, which might include questions that the patient feels the physician must answer personally before the patient feels informed and becomes willing to consent. The duty to obtain the patient's informed consent belongs solely to the physician.”

The landmark judgement of Supreme Court of India in the case of Samira Kohli vs Dr. Prabha Manchanda & Anron 16 January, 2008 has summarized principles relating to consent as follows in section 32.

     i.        “A doctor has to seek and secure the consent of the patient before commencing a 'treatment' (the term 'treatment' includes surgery also). The consent so obtained should be real and valid, which means that: the patient should have the capacity and competence to consent; his consent should be voluntary; and his consent should be on the basis of adequate information concerning the nature of the treatment procedure, so that he knows what is consenting to.

    ii.        The 'adequate information' to be furnished by the doctor (or a member of his team) who treats the patient, should enable the patient to make a balanced judgment as to whether he should submit himself to the particular treatment as to whether he should submit himself to the particular treatment or not. This means that the Doctor should disclose (a) nature and procedure of the treatment and its purpose, benefits and effect; (b) alternatives if any available; (c) an outline of the substantial risks; and (d) adverse consequences of refusing treatment. But there is no need to explain remote or theoretical risks involved, which may frighten or confuse a patient and result in refusal of consent for the necessary treatment. Similarly, there is no need to explain the remote or theoretical risks of refusal to take treatment which may persuade a patient to undergo a fanciful or unnecessary treatment. A balance should be achieved between the need for disclosing necessary and adequate information and at the same time avoid the possibility of the patient being deterred from agreeing to a necessary treatment or offering to undergo an unnecessary treatment.

   iii.        Consent given only for a diagnostic procedure, cannot be considered as consent for therapeutic treatment. Consent given for a specific treatment procedure will not be valid for conducting some other treatment procedure. The fact that the unauthorized additional surgery is beneficial to the patient, or that it would save considerable time and expense to the patient, or would relieve the patient from pain and suffering in future, are not grounds of defence in an action in tort for negligence or assault and battery. The only exception to this rule is where the additional procedure though unauthorized, is necessary in order to save the life or preserve the health of the patient and it would be unreasonable to delay such unauthorized procedure until patient regains consciousness and takes a decision.

   iv.        There can be a common consent for diagnostic and operative procedures where they are contemplated. There can also be a common consent for a particular surgical procedure and an additional or further procedure that may become necessary during the course of surgery.

    v.        The nature and extent of information to be furnished by the doctor to the patient to secure the consent need not be of the stringent and high degree mentioned in Canterbury but should be of the extent which is accepted as normal and proper by a body of medical men skilled and experienced in the particular field. It will depend upon the physical and mental condition of the patient, the nature of treatment, and the risk and consequences attached to the treatment.”

The UK Supreme Court took quite the opposite stance to Samira Kohli vs Dr Prabha Manchanda on informed consent in the matter of Montgomery v Lanarkshire Health Board in 2015. Subsequent to this judgement, Bolam test has legally become an ineffective tool to establish standard of care in cases of alleged medical negligence. It allowed the doctor the right to withhold information about risks associated with the proposed treatment, if he believes that the particular treatment is the only hope for a cure for the patient. Post-Montgomery judgement, doctors in the UK have now to take care now that “the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments”. The test of materiality would be whether “a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it." “The “therapeutic exception” is not intended to enable doctors to prevent their patients from taking an informed decision. Rather, it is the doctor’s responsibility to explain to her patient why she considers that one of the available treatment options is medically preferable to the others, having taken care to ensure that her patient is aware of the considerations for and against each of them.” This ruling has also taken away the therapeutic privilege of the doctor.

In the case of Dr Hadiza Bawa-Garba vs GMC, the UK Supreme Court charged Dr Hadiza Bawa-Garba and two nurses with manslaughter by gross negligence for the preventable death from sepsis of a 6-year-old boy with Down syndrome in 2011. Her name was erased from the medical register following an appeal by the GMC. She was held responsible for a sequence of failings.

  • “She did not recognize the early features of sepsis in the child and as such appropriate antibiotic treatment was delayed.
  • She appeared not to recognize the implications of seriously deranged blood gas results and failed to fully communicate the implications to her consultant.
  • When the child suffered a cardiac arrest there was a further problem as the patient was wrongly identified as another child for whom a DNACPR order applied.

Inquiry revealed that multiple errors and failings contributed to the mishap. No one cause could be found that led to the death of the patient.


  • Dr Bawa-Garba had only recently returned to work following maternity leave
  • She was covering the work of another registrar, with her supervising consultant teaching on a different site, and the two junior colleagues, for whom she had supervisory responsibility, had no pediatric experience.
  • She was expected to review unwell patients and perform procedures on six wards over four floors, field the GP calls and struggle without a functioning IT system.
  • The patient was shifted to a bed previously occupied by a patient with a DNR order; that change had been made without her knowledge. She was blamed for failing to recognize this.”

This judgement discounted system errors that may have contributed to the death of the patient. It also shows that “to err is human” can no longer be a defence, at least in the UK for the time being. But this is a case that is waiting to happen in India.



Dr KK Aggarwal
Padma Shri AwardeeVice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA


Sunday, July 1, 2018

On this Doctor’s Day, let’s pledge to change with the changing times


Patients are the most important part of the delivery of health care. They form the epicenter of the healthcare team and there is no stakeholder bigger than them in this relationship between patients, doctors and the healthcare team.

Today patients are more aware about their illnesses courtesy the Internet. Even this group of aware patients can be categorized into four based on their levels of awareness: Ignorant, Informed, Empowered and Enlightened.

·         Ignorant patients do not participate in decision making and depend on the doctor to make their decisions, with no questions asked.
·         Informed patients have questions for the doctor, but only few. These patients then usually agree to the line of treatment adopted by the doctor.
·         Empowered patients have many more questions, they cross check facts and are an equal partner in decision making regarding their treatment.
·         Enlightened patients seek the opinions of many are only then convinced about the proposed line of treatment. Convincing these patients involves several counseling sessions.

There has been rapid shift in from patients who are ignorant to patients who are enlightened. But, there has been no corresponding change in the attitudes and behaviors of doctors.

Miscommunication leading to mistrust is at the root of many doctor-patient disputes. This occurs when the level of awareness of the doctor and the patient do not match.

So, there can also be three types of doctors.

·         Doctors who expect patients to accept what they say.
·         Doctors give choices to patients and ask them to choose.
·         Doctors who give choices to their patients, but help them to choose the best option.

Enlightened patients are more legal-savvy. They are more aware of their rights. The obvious outcome is the rising numbers of medical malpractice claims against doctors.

Four judgements have created a paradigm shift in medical practice today.

Compensations amounting to more than one crore were awarded by the Supreme Court of India and National Consumer Disputes Redressal Commission (NCDRC) in three judgements.

·         In Nizam Institute of Medical Sciences vs Prasanth S Dhananka and Ors SC / 4119 of 1999 and 3126 of 2000, the Apex Court directed Nizam’s Institute to pay Rs.1 crore as compensation in lieu of medical negligence.

·         In Balram Prasad vs Kunal Saha & Ors on 24 October, 2013, the Supreme Court awarded a compensation of Rs. 6.08 crores to Dr Kunal Saha and this figure reached a staggering Rs. 11 crores after addition of interest.

·         Then, in the case of Dr. (Mrs.) Indu Sharma vs Indraprastha Apollo Hospital, April 2015, the NCDRC again awarded a compensation of Rs 1 crore to the parents of the child who was born with 95% disability.


Judgements of the Supreme Court of Pennsylvania in Shinal vs Toms and the United Kingdom (UK) Supreme Court in Montgomery v Lanarkshire Health Board and Dr Bawa Garba v General Medical Council have revolutionized the way we practice. These judgements were not delivered by any court of law in India, but the day is not far off when these would be considered relevant and become applicable in Indian settings also.

Shinal vs Toms said the consent is non-delegable and is the sole duty of the treating physician.

Montgomery v Lanarkshire Health Board negated Bolam’s law and has made it mandatory for UK doctors to inform patients of all possible risks, even though rare and benefits of the planned treatment including risks and benefits associated with the alternative treatment options and let the patient take a decision.

In Dr Hadiza Bawa-Garba vs GMC, the UK Supreme Court sentenced Dr Bawa-Garba to two years imprisonment after she was found guilty of manslaughter and convicted for gross negligence. The aftermath to this judgement is that to err is human is no longer a defense now in the UK.

The answer to all this lies in diligent informed consent to be taken at the time of the first consultation itself. Give detailed information to the patient. All material facts, which will help the patient to reach to an appropriate decision such as diagnosis, proposed treatment, risks and benefits of the treatment, alternative treatments along with their associated risks and benefits and also the risks of refusal should be disclosed. Some questions such as should the consultation be video/audio recorded by the doctor and the patient, can the patient call the doctor at any time of the day and can a junior doctor delegate by the doctor treat the patient in his absence? Also, limit your compensation beforehand.

The times and people have changed. We might not like how this has affected the doctor-patient relationship from when the doctor was the sole decision maker and his word was literally the law, which the patient was expected to accept and follow. From a paternalistic role, doctors have now to adjust to patients becoming equal partners in decision making.

These changes are here to stay.

Let us change with the changing times and accept them as they are …


Dr KK Aggarwal
Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Immediate Past National President IMA