Outpatient acute seizure management at the level of the general practitioner clinic: a proposed treatment algorithm

Outpatient acute seizure management at the level of the general practitioner clinic: a proposed treatment algorithm


Prahlad K Sethi, MD1 Dhrumil Shah, MD1 Anuradha Batra, MD 1 Nitin K Sethi, MD2


1 Department Neurology, Sir Ganga Ram Hospital, New Delhi, India

2 Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)



Seizures beget seizures has been a point of contention over the years. There is some scientific evidence to suggest that each seizure increases the risk for future seizures and that failure to control seizures in a timely fashion can lead to status epilepticus (SE). Status epilepticus is a life threatening neurological emergency which can present as an exacerbation of a pre-existing seizure disorder such as in an epilepsy patient who is non-compliant with his anti-epileptic drug (AED) regimen or as the initial manifestation of a seizure disorder (epilepsy) or as the manifestation of other systemic and cerebral insults. Prolonged seizures are also associated with worse neurological outcomes. With the aim to reduce the time to treatment gap, outpatient treatment of seizures is now been explored. We discuss this approach in relation to the health care system of India.


General practitioners (GPs) also referred to as primary care physicians (PCPs) form the backbone of the Indian health care delivery system. Usually, they are in solo practice working in small clinics (offices) which are ill-equipped to handle medical and surgical emergencies such as seizures and SE.

As awareness about coronary artery disease has increased, GPs now feel comfortable administering aspirin and nitrates before transferring the patient to the hospital. With respect to emergency management of seizures, their knowledge and experience is more limited. If the seizure has stopped, the patient is usually referred to a neurologist. If the patient is actively seizing, the patient is referred to the nearest hospital. The time to treatment gap results in increased morbidity and mortality especially for patients presenting with SE. Unlike developed countries, India lacks a well-organized and responsive 911 type medical emergency system manned by well trained and certified emergency medical technicians (EMTs) and paramedics who can administer life-saving 1st line and 2nd line antiseizure medications such as benzodiazepines (lorazepam, diazepam) and phenytoin or fosphenytoin parenterally en-route to the hospital.


Status epilepticus is a neurological emergency. Early effective treatment of SE results in termination of seizure activity and thereby reduction in cerebral hypoxia and damage. Hence every effort should be made to treat SE at the earliest. In India this goal would be best achieved by initiation of treatment of SE at the GP level. Till recently only intravenous benzodiazepine (diazepam or lorazepam) or rectal diazepam was available for the emergent management of seizures and SE. Now drugs which can be rapidly administered via the intranasal or intramuscular routes are also available such as intranasal midazolam and intramuscular fosphenytoin. Neurocritical Care Society guidelines recommend the administration of benzodiazepines via rectal, intramuscular, intranasal or buccal routes if intravenous or oral administration is not feasible. 1Administration via the above routes has been determined to be quick, easy, safe and to achieve high and consistent blood levels of the active compound. 2


We feel that antiseizure drugs in these formulations can be easily administered by a GP at the clinic without any special expertise or formal training.


















Intranasal midazolam: Currently in Indian market 2 midazolam formulations are available, one is MIDACIP (Cipla Pharmaceuticals) and other is MIDASPRAY (Intas Pharmaceuticals). They are both metered spray preparations. Two strengths of MIDACIP are commercially available: (1.25mg and 0.5mg)


Method of administration of MIDACIP nasal spray (Figure 1):



  1. Shake the bottle gently.
  2. Remove the dust cap.
  3. Hold the bottle with your forefinger and middle finger on either side of the nozzle and your thumb underneath the bottle
  4. If using first time, spray it six times in the air with the nozzle pointing away from the patient until the consistent mist of the drug is delivered, this is called priming, which ensures that correct dose is delivered.
  5. If the patient is in supine position, head is slightly lifted upwards and the device should be placed near the patient’s nose.
  6. Insert the nozzle into patient’s nostril, depress the pump with a firm even stroke. (Patient need not inhale)
  7. Tilt the patient head backward while spraying, this will avoid swallowing of the solution.
  8. Administer one spray at a time in each nostril to continue prescribed dose
  9. Reprime the device for subsequent use if the bottle is not used for more than a day. To reprime spray it two to three times in the air until a fine mist appears. For reusing the device nozzle and dust cap must be washed before storage.





Figure 1. Method of administration of intranasal midazolam.


Each nasal spray delivers either 1.25mg or 0.5mg of midazolam. Dose is titrated according to individual patient weight and full effective dose should be administered. For adults, dose is 5 mg if weight <50 kg and 10 mg if weight>50 kg. The dose should be equally divided and administered into each nostril. For children the recommended dose of MIDACIP nasal spray is 0.2 mg/kg body weight. The dose should be equally divided and administered into each nostril. Placing half the medication in each nostril reduces the volume while doubling the available surface area for absorption.



Table 1. Dosing Guidelines of MIDACIP Nasal Spray in children


Age (years) Weight (kg) Dose (mg) Metered Doses in Each Nostril
½ – 1 <10 1.25 – 2 1 – 2
1 – 4 10 – 16 2.5 2 – 3
4 – 10 16 – 32 5 4 – 6
>10 > 32 10 10









Intramuscular midazolam and fosphenytoin: GPs by virtue of their training can administer intramuscular injections with ease. In India intramuscular midazolam (MIDAZ, Abbott Healthcare or FULSED, Ranbaxy Laboratories) injections are widely available and cost effective. Midazolam is given intramuscularly at the dose of 10mg once or 0.2mg/kg once but not exceeding 10mg. Intramuscular fosphenytoin formulations are also available (Fosolin, Zydus Cadila Healthcare or Fosphen, Intas Pharmaceuticals) but more expensive. These preparations are available as ampoules of 150mg (75mg/ml, 2ml). It is our recommendation that the GP administer 2 ampoules of fosphenytoin stat in the clinic prior to transporting the patient to the hospital. Doing so may abort the seizure and possibly terminate the SE.



Use of the above formulations in the clinic setting by the GP along with established seizure first aid guidelines (Figure 2) has the potential to save many lives and reduce the morbidity from seizures and SE in our country.











Figure 2. Seizure first-aid guidelines (Source: Epilepsy Foundation Eastern Pennsylvania, www.epepa.org)





  1. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3–23.


  1. Agarwal SK, Cloyd JC. Development of benzodiazepines for out-of-hospital management of seizure emergencies. Neurol Clin Pract. 2015; 5:80-85.




Reemergence of remote concussion symptoms in amateur athletes after minor head bumps-a report of 2 cases

Nitin K Sethi, MBBS, MD, FAAN

Department of Neurology, New York Presbyterian Hospital Weill Cornell Medical Center, New York, U.S.A.





The 2012 Zurich Consensus Statement defined concussion as a complex pathophysiological process affecting the brain induced by biomechanical forces. Concussive and post-concussion symptoms are currently thought to reflect a functional rather than structural disturbance typically resolving spontaneously with no imaging abnormality. The majority of patients with concussion recover within a 7-to-10 day period, in some symptoms persist beyond the 1 month generally accepted time frame for recovery. Some patients recover within the above generally accepted time frame but show reemergence of concussion symptoms after minor head bumps. Two such cases in amateur athletes are reported here.








Case report

A 34-year-old right handed lacrosse player suffered a mild grade of concussion about 1 year ago when while playing, he was struck on the head by an opponent’s stick. No immediate loss of consciousness was reported. He experienced headache and light headedness for 1 day with spontaneous resolution.  After a month, there was sudden reappearance of headache. His physician ordered MRI brain and MRA brain, both of which were reported normal. Headaches again self-resolved. Since then he reports headache only when he bumps his head into something, usually a trivial bump or when he exercises. A 64-year-old right handed amateur skier reported slipping and falling on ice about 8 years ago. Landed on his head and said he was “out” for about 15-30 seconds. When he came to, he felt nauseated. Next day consulted a neurologist. CT scan head was normal. Went back to work after 1 week. Since then every time he bumps his head, symptoms of nausea, feeling like he is in a funk, light and sound sensitivity return. Sometimes these last for about 1 week with spontaneous resolution. Consulted a neurologist, migraine was suspected and he was prescribed anti-migraine medication which didn’t work.






The 2012 Zurich Consensus Statement defines concussion as a complex pathophysiological process affecting the brain triggered by biomechanical forces. 1Typically most people recover from a concussion within 2 weeks of the injury. In about 10 to 20 percent of cases symptoms of concussion may persist longer. Post-concussion syndrome (PCS) refers to the persistence of concussion symptoms beyond the acute post-injury period and includes a constellation of disparate symptoms such as headache, nausea, dizziness, attention and concentration problems, impairment of short term memory, a sensation of fatigue (both physical and mental), light and sound sensitivity, irritability, insomnia and emotional liability. 2, 3 Studies have identified older age, high initial concussion symptom load, duration of loss of consciousness and post-traumatic amnesia, pre-existing anxiety and depression as predictors of persistent PCS.4, 5 The reemergence of remote concussion symptoms after minor head bumps has not been reported in the medical literature. These are patients who report typical concussion symptoms following head trauma which typically resolve within the normal time frame of acute post-injury period. However these asymptomatic patients periodically report the reemergence of their remote concussion symptoms with the inciting trigger typically reported to be a minor bump to the head or some other cognitive or physical stressor such as going to a rock concert or an increase of stress at work or home.


The underlying etiopathogenesis of this phenomena remains largely enigmatic and speculative. Whether this is a variant of persistent PCS is unclear.4, 5 While in persistent PCS there is usually no return to baseline after the inciting concussion event, the patients reported have reemergence of their remote concussion symptoms only following a minor head trauma typically low velocity and low intensity bumps to the head with return to pre-morbid baseline and functioning in-between. Underlying migraine predisposition has also been postulated as one possible etiology. 6, 7 While this is a viable hypothesis, the patients reported above had no pre-morbid migraine symptomatology (no headaches prior to the concussion). They also lacked the typical prodrome, ictal and postictal symptomatology of either classical or common migraine attacks. The third explanation for the reported phenomena is that it is a manifestation of a conversion disorder (neurologic symptoms or deficits that develop unconsciously and nonvolitionally and usually involve motor or sensory function).


The reemergence of the remote concussion symptoms is incompatible with known pathophysiologic mechanisms or anatomic pathways. The onset, exacerbation, maintenance or reemergence of these symptoms is likely directly attributable to mental factors, such as stress and anxiety. The treatment involves reassurance after judicious diagnostic testing to rule out any organic etiology.







  1. McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvoøák J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis GA, Ellenbogen RG, Guskiewicz K, Herring SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M, Schneider K, Tator CH, Turner M. Consensus statement on concussion in sport: The 4th International Conference on Concussion in Sport held in Zurich, November 2012.British Journal of Sports Medicine. 2013; 47(5):250–258.


  1. Leddy J, Sandhu H, Sodi V, Baker J, Willer B. Rehabilitation of concussion and post-concussion syndrome. Sports Health: A Multidisciplinary Approach. 2012; 4(2):147–154.



  1. Makdissi M, Darby D, Maruff P, Ugoni A, Brukner P, McCrory PR. Natural history of concussion in sport: Markers of severity and implications for management. American Journal of Sports Medicine. 2010; 38(3):464–471.


  1. Makdissi M, Cantu RC, Johnston KM, McCrory P, Meeuwisse WH. The difficult concussion patient: What is the best approach to investigation and management of persistent (>10 days) postconcussive symptoms. British Journal of Sports Medicine. 2013; 47(5):308–313.



  1. McCrea M, Guskiewicz K, Randolph C, Barr WB, Hammeke TA, Marshall SW, Powell MR, Woo Ahn K, Wang Y, Kelly JP. Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes.Journal of the International Neuropsychological Society. 2013; 19(1):22–33.


  1. Mihalik JP, Register-Mihalik J, Kerr ZY, Marshall SW, McCrea MC, Guskiewicz KM. Recovery of posttraumatic migraine characteristics in patients after mild traumatic brain injury.American Journal of Sports Medicine. 2013; 41(7):1490–1496.



  1. Weiss HD, Stern BJ, Goldberg J. Post-traumatic migraine: Chronic migraine precipitated by minor head or neck trauma. Headache. 1991; 31(7):451–456.

Can boxing be made safer? Yes but the culture needs to change

N K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America



Disclosure and Disclaimer: N.K Sethi serves as Chief Medical Officer for the New York State Athletic Commission (NYSAC). The views expressed are his only and do not reflect the views of the NYSAC.

KEY WORDS: boxing; traumatic brain injury; concussion; death



Recently the boxing world has been mourning the loss of a number of boxers in the ring or in the immediate aftermath of a bout.  As physicians we take an oath to always protect the health of our patients and while ringside medicine is practiced in a different arena than within the confines of a hospital or ER, our duties and obligations to protect the health and safety of the fighters should never waiver for when they enter that ring or cage, they entrust us with their most precious possession of health. Few realize the pressures doctors work under at ringside. Once I had to make the difficult decision to stop a bout on medical grounds with only 30 seconds left on the clock in the last round. I stopped the fight only to be berated by the fighter’s corner like I have never been before. The F word was used repeatedly for what I had done and I was told in rather colorful language of what they thought of my action. I remained calm and stepped away after ensuring the fighter was safe.


As I see it, when I “hung up my gloves” at the end of a long night, I had the satisfaction of knowing that I had done the job which I am entrusted with to the best of my capability. That job is to protect my fighter first and foremost. As a fan, yes I may see it differently and want the fight to go down to the end but we are not there in the capacity of a fan of the sport, we are there as doctors with one and only one job to protect the fighter.


Yes 30 seconds in boxing do matter. In boxing one punch can be the difference between life and death. One punch can kill! So while we as ringside physicians endure the wrath of the corners, the media and sometimes the fighter himself let us not let this discourage or intimidate us to comprise on fighter safety. In the end there is nothing like going to bed with a feeling of a job well done.


We have to continuously strive to provide the best medical care and attention to the fighters. Analyzing what we do and improving our current medical policies and protocols should be an ongoing task. The more time I spend ringside, the more I realize that boxing is a unique sport for a physician to be involved in and that the odds are stacked against us ringside.  In the office or hospital/ ER setting, a patient comes to us mostly voluntary seeking help and care. On questioning, he/she gives us a detailed history. The family is at times there to supplement the history. Contrast that to the ringside where on direct questioning, frequently the patient (boxer) and his family (corner) falsely deny that anything is wrong and are often upset and angry that we even dared to ask the question. After a fight is over, it is not infrequent to encounter a boxer and his corner who refuse to go to the ER for medical evaluation. “I am fine doc, I am not going” is the deviant answer. These boxers and their corner staff fail to appreciate that symptoms in some people with head injuries don’t show up immediately! (walking, talking and dying syndrome). That is the reason why physicians recommended to observe people after a head injury for 24 hours.


When I last checked, none of us physicians have X-ray vision so how are we expected to make a medical call from a distance without the benefit of an honest history or a quick examination?  Many do not realize that once a brain bleed has occurred and the pupils are unreactive (fixed) and dilated, there is precious little we physicians can do ringside to “save” that athlete. Even if that athlete reaches the hospital alive in a timely fashion as a result of our collective efforts, the resulting decompressive surgery is carried out as a last ditch palliative life-saving procedure. That athlete shall never be the same again and will have significant residual neurological deficits. Our goal should be to prevent such a devastating injury from ever occurring in the first place and not just to manage it after it has unfortunately occurred.


A few years ago, I wrote a short letter  titled “Boxing can be made safer” in response to an editorial in a leading neurology journal calling for a ban on boxing and MMA. I argued passionately that boxing and MMA can be made safer with improved medical policies designed to protect the health and safety of the combat sport athlete. I still stand by my stated position that boxing can be made safer but the change has to come from inside. In the National Football League (NFL), the culture has already changed from a previously held view of “suck it up and shake it off” to one of “if you feel something, sit it out“. Athletes are now encouraged to report their symptoms of concussion/traumatic brain injury (even if minor and subjective) to the athletic trainers and doctors on the sidelines.


The word “No mas” (Spanish for “No more”) gained boxing notoriety when Sugar Ray Leonard fought Roberto Duran II on November 25, 1980. At the end of the eighth round Durán turned away from Leonard towards the referee and quit by apparently saying, “No más“.  Duran’s stature was never the same again after he uttered those 2 words. Over the years, the boxing culture has evolved to one of never saying “No mas”. The fighter’s mentality is never to quit no matter what the circumstances. Doing so brings disgrace to the fighter, his family and his corner. This mentality and culture needs to change, Boxers and corner staff should be educated and encouraged to actively recognize and report to the ringside physician any subjective symptoms of concussion and TBI such as headache, subjective feeling of dizziness or light headedness, blurring of vision, double vision, confusion and a feeling of fogginess. “When in doubt, sit it out” is not equivalent to “No mas”. “For he that fights and walks away, may live to fight another day” historically attributed to Demosthenes, a Greek orator should be the new mantra of boxing. There is no shame in this; just smartness.


The boxing culture needs to change and this change shall come over time with education. As physicians it is our duty to educate the boxing community and I hope physicians who practice ringside medicine shall join me in this effort.


Together we can make a difference and making boxing safer.






Good versus bad medical stoppages in boxing-stopping a fight in time

Good versus bad medical stoppages in boxing-stopping a fight in time


Nitin K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)





In boxing it is commonly said and not without reason “the fight must go on….”.  Everyone ringside wants the fight to go on-the two boxers and their corners (sometimes not always!), the promoter (always!), the media (always!), the spectators (always!), the Commission and its appointed officials (only if both the boxers meet the Commission requirements for a fair and honestly administered contest), the referee (only if the boxers are fighting a fair fight and able to defend themselves), the judges (usually do not interfere with the conduct of the fight!) and the ringside physicians (only if the boxers are medically fit before, during and immediately after the contest!). So everyone ringside want the fight to go on but do some (media, spectators and promoters) want it more than others? As per the Uniform Boxing Rules (approved August 25, 2001, Amended August 2, 2002, Amended July 3, 2008), the referee is the sole arbiter of a bout and is the only individual authorized to stop a contest. In some states in the United States and in countries around the world both the referee and ringside physician are the sole arbiters of a fight and are the only individuals authorized to enter the fighting area at any time during competition and authorized to stop a fight. The referee and the ringside physician threshold to stop a fight (enough is enough!!!) may vary based on knowledge of boxing rules and regulations, knowledge of the boxers fitness level, pre-existing medical conditions, pre-bout fitness, intra-bout fitness and finally knowledge of medicine and bout ending injuries (head injuries, orthopedic injuries, eye injuries, blunt abdominal trauma). That is the reason why it is the referee (someone who has knowledge of boxing rules and regulations) and the ringside physician (someone who has knowledge of medicine) who are deemed to be the sole arbiters of a bout and entrusted with the health and safety of the boxers. The other MORE important question is when should the fight be stopped on medical grounds? Stopping the bout prematurely is unfair to the boxers, their corners, the promoter and the public. Stopping a bout too late risks serious injury even death of the boxer.

Boxer safety should precede all other considerations. The goal should be to stop the bout before a life threating injury or career ending injury occurs. Key word is before NOT after. Since at times this is not possible so more realistic goal should be timely identification of a serious injury in the ring and timely stoppage of fight. For that to occur the referee and the ringside physician should work as a team complimenting each other’s knowledge. Causes of sudden death in the ring or in the immediate aftermath of a bout are usually neurological.

To help timely identify and prevent TBI in boxing the following good practice guidelines are proposed based on personal and collective evidence of experienced ringside physicians and clinical acumen:


  1. It is a good point to remember that boxers rarely if ever voluntary quit or request the fight to be stopped. They fight for pride, at times at the expense of their health. Corners may also not want the fight to be stopped with the hope that their boxer may turn things around. In a closely contested fight the crowd is excited and wants the fight to go on. At these times, the ringside physician should make the call to stop or let a fighter continue, based solely on the medical condition of the boxer.


  1. During the one minute rest period in-between rounds, the ringside physician should step up to the ring canvas for a quick but thorough medical evaluation of the fighter.


  1. This is the ideal time for the ringside physician to assess the neurological status of a fighter. In the case of a fighter who suffered a knock down in the preceding round or sustained multiple head shots, the ringside physician should conduct a quick visual evaluation of the fighter (Is the fighter responding appropriately to the commands and directions of his corner? Is he making eye contact with his corner staff? Was the fighter steady on his feet as he walked back to his corner at the end of the round? Does the fighter voice any complaints to his corner staff such as headache or pressure in head, dizziness, and blurred vision?). The ringside physician should attempt to do the above without obstructing or imposing on the corner’s time with its fighter.


  1. If the ringside physician determines that he/she needs more time to evaluate the neurological status of a fighter, he/she should communicate this to the referee. The referee after starting the bout shall call a time out and walk the fighter to the ringside physician to be examined. The referee directs the other fighter to remain in the neutral corner. The ringside physician’s goal at this time is to conduct a quick but thorough neurological assessment of the fighter. He/she should begin this by asking the fighter few leading questions such as-how do you feel? Does your head hurt? Do you know where you are? If the fighter appears confused and disoriented, the ringside physician may ask more question like which round is it? Who is your opponent? Where are you fighting (name of the venue)? The ringside physician should then look for pupil symmetry and response and assess extra ocular movements (have the fighter track finger from side to side). The ringside physician should give the fighter a complex command such as touch your left ear with right glove and should assess the fighter’s gait and balance at the same time (is the fighter steady on his/her feet or is he leaning on the ropes for support). The ringside physician should then communicate to the referee whether the fighter can continue or the fight should be stopped. The whole process should not take more than 10 seconds.


  1. The ringside physician should be aware that too much time spent evaluating the fighter during time out, inadvertently gives the fighter more time to recover. The opponent’s corner rightfully resents this and it is akin to getting “saved by the bell”. The public, TV audience, press and TV announcers question the fairness of the Commission’s administration of the contest and the credibility and impartiality of the bout officials-e.g., referees, judges and ringside physicians.


  1. If serious health concern is raised for a fighter and the ringside physician is unable to document a good exam to determine whether it is safe for the fighter to continue, consideration should be given to stopping the fight. In these circumstances the ringside physician should tell the referee that the fight be stopped on medical grounds.


  1. For ringside physicians with limited ringside experience, it is encouraged that they consult with other ringside physicians at the venue and the chief medical officer before deciding to stop a fight on medical grounds.









As injuries mount, the boxing community is looking within and the sport is under scrutiny from the medical community and media. Boxing is the most controversial sport for physicians and neurologists in particular because of the potential risk and degree of neurologic injury, questions and concerns about long-term sequelae (chronic traumatic encephalopathy), and the occurrence of deaths in the ring  . Various medical associations including the American Medical Association and the American Academy of Pediatrics have stated opposition to both amateur and professional boxing . Many have called to ban boxing altogether . Dr. Hauser in a recent editorial titled “Beaten into action: a perspective on blood sports” says that “the medical, and especially the neurology, community has an obligation to do more. We need to spread the word that brain bashing is not a socially acceptable spectator sport, and partner with our national organizations to expand and improve the effectiveness of public awareness and other educational initiatives.” He further goes on to state “we should forcefully counter articles in the medical literature taking the position that closer medical supervision could obviate the need for a ban, or even worse that consenting adults have the ethical right to maim each other if they choose to do so .” While the neurological risks of boxing cannot be completely eliminated, boxing can be made safer .







It is recommended that the above proposed best practice guidelines be debated vigorously by the ringside physician and large scientific community and evidence based guidelines on medical stoppages be developed by the medical community in conjunction with professional boxing governing bodies. Boxing can be made safer but it shall be foolhardy to forget that frequently there is a very fine line between a good medical stoppage (medical stoppage done at the right time during the bout and for the right indication) versus a bad medical stoppage (medical stoppage done either too late, too prematurely or for the wrong indication). It is far better to stop a fight early rather than late. A ringside physician should never forget that in boxing one punch can change everything. One punch can kill!


Dying with dignity– free from machines

Prahlad K Sethi 1 and Nitin K Sethi, MD2


1 Department Neurology, Sir Ganga Ram Hospital, New Delhi, India

2 Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)




In recent years, rapid advances in medicine and critical care have produced a plethora of procedures (endotracheal intubation, central venous lines placement, tracheostomy) and medical devices (mechanical ventilators, infusion pumps, dialysis machines) to support and sustain life. For physicians, caregivers and most importantly patients it is more important than ever before to make wise decisions about life-sustaining medical treatments. End-of-life (EOL) decision making process though is complex and involves difficult decisions for all concerned (patients, caregivers, physicians and nurses).


The Hippocratic Oath requires a newly minted physician to swear by the healing gods of Apollo, Asclepius, Hygieia and Panacea that he/she shall withhold certain ethical standards. The classical version of the oath hints at applying for the benefit of the sick, all measures that are required/available. Physicians hence by virtue of their training are programmed to support life by all measures at their disposal. The modern version of the oath advices physician to do the above while avoiding the twin traps of overtreatment and therapeutic nihilism. Unfortunately in medical schools across India, physicians in training are not taught how to avoid these two traps. When does a physician say no more? How does he communicate the futility of further medical treatment to the patient and the caregiver/family? There are no simple answers to the above questions. Disagreement about the goals of treatment between patient, family members and physician providers leads to misunderstanding and distrust.







For physicians it is important to treat the patient and family members humanely as EOL approaches. This begins with a clear explanation of the disease process and prognosis to the patient and his family. What is the life expectancy, what can the patient and family expect as the disease progresses? Will the various procedures and devices available to support and sustain life, have a meaningful outcome in the long term. For a physician it is important to prognosticate on not just life expectancy but also on the quality of life after these procedures/ interventions. Will the patient be able to talk, eat, walk independently or will he be bed bound, dependent on a dialysis machine, with a tracheostomy and feeding tube? All these questions no matter how difficult, need to be addressed with the patient and his family.  In the movie The Wrath of Khan (1982), Spock in his usual logical way says “the needs of the many outweigh the needs of the few” (“or the one”). Doctors have a moral obligation to not just the patient in front of them but also to the larger society. They have to wrestle with questions whether the medical resources currently devoted to their patient could be better utilized for care of other potentially salvageable patients. But a doctor should never forget that in the  patient or family member’s eye “the needs of the one may outweigh the needs of the many”.













Case-1 A-85-year old lady, diagnosed with a brain tumor (glioma)  3-4 months back and on antiepileptics, presented to the casualty with recurrent seizures. On presentation, she had a Glasgow Coma Scale (GCS) score of 3. She was loaded with IV antiepileptics. Though she warranted admission to the intensive care unit, she was admitted to the neurology floor respecting the wishes of her family who declined intubation and mechanical ventilation. Surprisingly her sensorium improved the next day and she started to communicate and accept orally. She though again declined. Respecting her and the family’s wishes, palliative care and comfort care measures were instituted. She went into a sudden cardiorespiratory arrest on day 3 and passed away peacefully with her family by her side.


Case –2: A-87-year old lady, known case of hypertension with coronary artery disease (CAD) status-post coronary artery bypass grafting (CABG) and angioplasty came to our casualty with sudden loss of consciousness. On examination, she was found to have left-sided hemiparesis with poor GCS score. CT head revealed sulcal effacement with early developing hypodensity in large area of right middle cerebral artery (MCA) territory. MRI brain confirmed large right hemispheric infarct and left posterior cerebral artery (PCA) territory infarct. After the poor prognosis was explained to the relatives, they decided to pursue palliative care. Do not intubate (DNI) and do not resuscitate (DNR) orders were signed. Patient went into cardiac arrest and passed away.


Case-3: A-86-year old bed bound male, known case of advanced Parkinson’s plus disease with dementia, presented with history of decreased oral intake, difficulty breathing, fever and altered sensorium for 2 days. He was encephalopathic with bilateral aspiration pneumonia and sepsis. After the poor prognosis was explained to family members, they elected against intubation and mechanical ventilation. He was managed on the neurology floor with oxygen, non-invasive mechanical ventilation (BiPAP), nebulization, chest physiotherapy with periodic suctioning along with IV antibiotics and other supportive care treatments. Due attention was given to hydration and nutrition status. Five days later, he developed sudden cardiorespiratory arrest and passed away.


Case-4: A- 61-year old lady, having multiple co morbidities (old stroke with right sided hemiparesis, diabetes, hypertension, interstitial lung disease, old pulmonary tuberculosis, chronic liver disease with anemia) presented with complaints of diarrhea, fever and breathlessness for 2 days. She was found to have bilateral pneumonia with hypoxemia. After the poor outcome was discussed with relatives in terms of possibility of difficulty weaning off from ventilatory support, they elective to pursue comfort care measures. Patient was managed with IV antibiotics, antihypertensive, antidiabetic and other supportive treatments along with non-invasive (BiPAP) ventilation. She passed away 6 days after admission with her family by her bedside.




Dying with dignity


On March 7th, 2011, the Law Commission of India, Ministry of Law and Justice in a landmark judgment recommended to the Government of India that terminally ill patients should be allowed to end their lives. By passing this judgment, India joined a small select group of nations that allow euthanasia in some form or other. This judgment has led to a vigorous debate in the media about euthanasia and the right to die. Just what is euthanasia and what is the difference between active and passive forms of euthanasia? The word euthanasia is derived from Greek: eu ‘well’ + thanatos ‘death’. The Oxford dictionary defines euthanasia as the practice of killing without pain a person who is suffering from a disease that cannot be cured1. The Stedman’s medical dictionary gives a more comprehensive definition and defines it as the act or practice of ending the life of an individual suffering from a terminal illness or an incurable condition, as by lethal injection or the suspension of extraordinary medical treatment2.

Active euthanasia (as for example mercy killing via a lethal injection or by giving an overdose of pain killers and sleeping pills) is currently illegal in almost all countries of the world. In most countries a physician who assists in active euthanasia can be prosecuted, lose his license to practice medicine and can even be jailed. The patient requesting active euthanasia can also be prosecuted. Put in another way the law as it stands now condemns a physician for actively killing someone (even though the patient requests it) but does not condemn a physician for failing to save a terminally ill patient’s life (aka active euthanasia is illegal but not passive euthanasia). Netherlands and Switzerland are two countries where active euthanasia is practiced openly though the medical, legal and social implications remain active topics for both professional and public debate. The courts in these two countries have allowed physicians to practice active euthanasia under certain strict conditions. In these countries too physician assisted euthanasia (the physician prescribes the lethal medication but it is the patient who self-administers the lethal medication) is more widely accepted (both by the public at large as well as ethically and morally by the physician community) than active euthanasia (physician administers the lethal injection himself). In Netherlands the following guidelines if followed strictly have traditionally protected physicians from prosecution: the patient’s wish to die must be expressed clearly and repeatedly, the patient’s decision must be well informed and voluntary, the patient must be suffering intolerably with no hope for relief however the patient does NOT have to be terminally ill (mental suffering is acceptable as a reason for performing assisted suicide and euthanasia in a patient who may be physically healthy), the physician must consult with at least one other physician, the physician must notify the local coroner that death resulting from unnatural causes has occurred 3.

There is an ever increasing demand for the “right to die with dignity”. In an essay in the International Herald Tribune the right to die was defined as follows: “every person shall have the right to die with dignity; this right shall include the right to choose the time of one’s death and to receive medical and pharmaceutical assistance to die painlessly. No physician, nurse or pharmacist shall be held criminally or civilly liable for assisting a person in the free exercise of this right.” A fundamental thought underlying the right to die is the belief that one’s body and one’s life are one’s own, to dispose of as one sees fit. So theoretically if one wants to commit suicide one should have the freedom/ right to do so. Opponents of the right to die point out that legalizing the right to die may lead to irrational suicides. Different religions have different thoughts of view when it comes to the right to die. Hinduism in fact accepts the right to die for those suffering from terminal illnesses allowing death through the non-violent practices of fasting to death (Prayopavesa). Some Jains practice Santhara by which they seek voluntary death through fasting. Since the decision to practice Santhara is taken while one possesses a sound mind and is aware of the intent it cannot be equated to suicide which is usually carried out in haste when a person is in the midst of depression they point out.



A form of passive euthanasia and dying with dignity by withholding extraordinary life supporting measures (such as the decision to intubate and mechanically ventilate a terminally ill patient) is already routinely practiced in critical care units across India on a daily basis. In our experience once the hopelessness of the medical situation and the gravity of the illness is explained to the patient and the relatives, they comprehend and at times request discharge from the hospital so that the patient can take his last breath at home surrounded by family and friends. It is only when disagreements about the need, timing or mode of termination of care arise among family members or when a conflict of interest is perceived by the family members with respect to the treating physicians (‘they want him to die so that they can have the bed/ ventilator’) that these cases reach the attention of the media and the public at large such as in the case of Aruna Shanbaug.


The right to die with dignity is a fundamental right of every person. The terms of this dignified death may vary from patient to patient. For some it may be dying at home surrounded by close family and friends, others in the hospital might wish to avoid the “trauma” of intubation and mechanical ventilation but continue with intravenous hydration and other comfort care measures, still others may wish for everything to be done. Doctors should explore patient and family’s wishes on these issues and respect them.





In the words of Frank Sinatra from his famous song “My way”…


“And now, the end is near
And so I face the final curtain
My friend, I’ll say it clear
I’ll state my case, of which I’m certain

I’ve lived a life that’s full
I’ve traveled each and every highway
But more, much more than this
I did it my way”


Men like “Tiger” Nawab Pataudi and Dara Singh not only lived their lives “their way” but also died on their own terms-with dignity.


Dying can be a peaceful event or a great agony when it is inappropriately sustained by life support.” –

Roger Bone






  1. Oxford dictionary online at http://oxforddictionaries.com
  2. Stedman’s Online Medical Dictionary at http://www.stedmans.com
  3. http://www.libraryindex.com/pages/573/Euthanasia-Assisted-Suicide