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This position statement aims to minimize inappropriate treatment and optimize palliative care for terminally ill patients in Indian intensive care units by standardizing the process of forgoing life support. It also defines the ethical standards for the physician-patient relationship in the context of critical care practice in India. Evidence: Evidence was gathered through a review of recently published medical literature on the subject, as well as by evaluating the relevant statutes of Indian Law. Available empirical data from critical care practice in India were sparse. Newspaper articles reflecting lay opinion on related issues were also reviewed. The terms for search were: end-of-life care; withdrawal and withholding; intensive care; terminal care; medical futility; ethical issues; palliative care. Method: Proposals from the Chair were debated and recommendations were formulated through a consensus process. The process took into account the guiding ethical principles and clinical practices elsewhere in the world, and incorporated the socio-cultural and legal perspectives unique to this country. Recommendations 1. The physician has a duty to disclose to the capable

Sudden and staged reperfusion after experimental coronary artery occlusion was studied in relation to recovery of cardiac function and postreperfusion arrhythmias. Eighteen closed chest dogs with 3 hour intracoronary balloon occlusion of the proximal left anterior descending coronary artery were studied using two-dimensional echocardiography over a period of 3 weeks after reperfusion. Nine dogs had sudden reperfusion by abrupt balloon deflation. In nine other dogs reperfusion was staged with partial reflow (20 ml/min) for 2 hours through the central lumen of the catheter during persisting intracoronary balloon inflation, followed by balloon deflation and full reperfusion. Within the first 30 minutes of sudden reperfusion, ischemic zone end-diastolic wall thickness increased significantly, from 6.8 +/- 0.3 mm at 3 hours of occlusion to 10.2 +/- 2.6 mm (p less than 0.05). In contrast, at 30 minutes of partial reflow, wall thickness was 7.5 +/- 0.7 versus 6.8 +/- 0.7 mm at 3 hours of occlusion (NS). A small temporary increase in end-diastolic wall thickness was noted when full reflow was established after 2 hours of staged reperfusion. However, wall thickness was normal on the first day in the staged reperfusion series, while sudden reperfusion delayed recovery to 7 days. Function of the ischemic zone failed to improve substantially until day 3 after sudden reperfusion, whereas it improved consistently starting as early as 30 minutes after institution of the staged reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Background:Therapeutic hypothermia (TH) may improve neurological outcome in comatose patients following out of hospital cardiac arrest (OHCA). The reliability of clinical prediction of neurological outcome following TH remains unclear. In particular, there is very limited data on survival and predictors of neurological outcome following TH for OHCA from resource-constrained settings in general and South Asia in specific.Objective:The objective was to identify factors predicting unfavorable neurological outcome at hospital discharge in comatose survivors of OHCA treated with hypothermia.Design:Retrospective chart review.Setting:Urban 200-bed hospital in Chennai, India.Methods:Predictors of unfavorable neurological outcome (cerebral performance category score [3–5]) at hospital discharge were evaluated among patients admitted between January 2006 and December 2012 following OHCA treated with TH. Hypothermia was induced with cold intravenous saline bolus, ice packs and cold-water spray with bedside fan. Predictors of unfavorable neurological outcome were examined through multivariate exact logistic regression analysis.Results:A total of 121 patients were included with 106/121 (87%) experiencing the unfavorable neurological outcome. Independent predictors of unfavorable neurological outcome included: Status myoclonus <24 h (odds ratio [OR] 21.79, 95% confidence interval [CI] 2.89-Infinite), absent brainstem reflexes (OR 50.09, 6.55-Infinite), and motor response worse than flexion on day 3 (OR 99.41, 12.21-Infinite). All 3 variables had 100% specificity and positive predictive value.Conclusion:Status myoclonus within 24 h, absence of brainstem reflexes and motor response worse than flexion on day 3 reliably predict unfavorable neurological outcome in comatose patients with OHCA treated with TH.

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