​Right now, I am in Mumbai’s SevenHills Hospital. My wife and I are among the first travelers to be quarantined in this facility that is being brought back to life to cope with the challenge posed by the coronavirus. I was last here when my grandson was born, and it used to be a thriving hospital then.
Now 8 years old, he was his usual happy and chatty self when the family gathered for lunch at a restaurant in Barcelona, Spain, on March 7, 2020. We were visiting our daughter’s family and we had happily extended our planned stay of one month by another 17 days.
After we reached home, a friend who was planning a visit to Spain on March 19 called up. I reassured him that there was no panic in Spain. There was no reduction in the number of tourists, and I had not seen anyone wearing a mask. Still 10 days to go, so let’s plan another lunch, I told my family.

​Then the viral panic caught up with us. The numbers started mounting. Both India and the US virtually shut their borders. Suddenly, we were in a dilemma.
We had insurance and sufficient stock of personal medicines. So, should we stay where we were in comfort or take the next flight out?
As the news got worse by the day, someone in the Indian embassy suggested we were better off leaving Spain as soon as we could. There was perhaps no escaping quarantine. At least we could avoid overstaying our visa.
We decided to leave. It was a painful task to console my grandson, who was heartbroken that we were going away when there were “still so many days left”.
We rescheduled our departure to Saturday, March 14. Around 10 the previous night came reports of flights being cancelled and turned back midair. We spent a sleepless night, not sure what lay in store, thinking of very many if-only scenarios.
Long queues greeted us at the airport. People were grabbing what everyone understood to be the last opportunity to fly home—Beijing, New York and, in our case, Mumbai.
Our Barcelona-Abu Dhabi-Mumbai flight was full all the way. Conversations were muted, movements circumspect.

We had been fully briefed about what to expect once we landed in Mumbai. I was confident that as my wife and I were free of symptoms, we would be asked to quarantine ourselves at home. Then came the instruction that we had to write our age prominently on top of the form we were filling in. We found ourselves in a separate queue for those above the age of 60.
Some people from Brihanmumbai Municipal Corporation (BMC) took charge of us. They took our bags and escorted us through various checks. A doctor told us that we would be taken to SevenHills Hospital, to be quarantined for 14 days. Just as a precaution, he assured us. Outside we were ushered into an air-conditioned bus.
We are now in a two-room facility at SevenHills. The building that had been closed for more than a year is being made functional floor by floor. People are at work round-the-clock.
They have been quick to set up Wi-Fi and a TV is being commissioned. All electrical and plumbing systems have been double checked.
“How many patients are there? And how much do we have to pay?” I was curious. “You are not a patient, sir!” came the reply. “You are a traveler and now you are our guest.” His smile would have felt at home in any five-star hotel.

​Every piece of information about the virus is out there. Every fresh case is being tracked. There is no shortage of posturing and blaming  across all sorts of divides: political, geographical and religious. There is fear, anger and frustration. There is naked display of self-interest as people dodge quarantine as if the virus is yet another system they can game.
I want to share this because there is also genuine courtesy, care and concern. The kind we are experiencing now.
I am grateful. To these people of those very government institutions we like to blame whenever anything goes wrong. Let us thank them for stepping up. And let us do our bit to help them.
When it is safe to do so again, I would like to shake more hands (if that gesture is still in vogue) and smile at more strangers. Complain less and think more of what I can do for the sake of all of us.
Personally, I hope we will emerge stronger from this quarantine. It has already shown me what we humans can be, if we just try. Why wait for a calamity?

they are all here
to make music together
the violinist
the organist
the guitarist
the percussionist
none knows the singer
nor the song
they are from different countries
the drummer’s country just attacked the singer’s
the violinist’s nation’s tussle with the guitarist’s
threatens to turn nuclear
but they are brought here
by the spontaneous harmony
of the heart, the pull of love
across borders, divisions and tongues
each lifetime is a bare flicker
in the grand scheme of things
in that fraction
we can choose
to hate, fight, destroy
or make music

[Reshma (Sri Lanka), 9:16 PM, 12/17/2019] Snake bite... What's the first aid pls help urgent...it's for me.
I saw the snake brown
[Shalini (Bengaluru)] Pls rush to a hospital .. there is no first aid .. let the doctor examine you ..
[Reshma] Ok doing that on the way
[Hasmukh (Sapna Ranch, Terdi Village, Sade, Maharashtra)] Are you able to judge of the snake is poisonous? Have you been able to catch the snake? Call Shalini right away. She is a member of this group and she lives in Bangalore. I'm assuming you are in Bangalore.
[Shalini] Stay calm and get to the nearest possible hospital quickly .. get some one to go with you
[Reshma] I am in Srilanka. ...brown thin snake
Donno if it's poisonous...
I know it's remote...
Didn't know what to do.. hence msged
[Hasmukh] Is its head bigger than its body?
[Shalini] Anti venom is the only solution.. only doctors can administer it based on the symptoms your body shows ..
[Nirav, (Mumbai)] Tie a tight tourniquet between the bite and heart avoid blood circulation
[Reshma] Ok
It bit me in my leg ankle
[Shalini] Anti venom needs to be administered based on your description of the snake bite ..
[Reshma] Putting a rubber band
[Nirav] Don't panic is anyone near you
[Reshma] Don't think so but not sure
[Nirav] No a dupatta tightly
[Shalini] Pls don't do that.. it can lead to non supply of blood causing gangrene and heavy tissue damage
[Reshma] Yes the hostel ppl r taking me to the hospital
[Shalini] Pls don't take any advice from non medical staff ..
[Reshma] Ok

[Shalini] I'm trained in snake bite and conflict management at Madras croc bank by snake experts .. pls just get to a hospital very quickly .. the earlier the better .. stay calm .. don't panic .. breathe normal .. hyper ventilation can lead to fast blood circulation and that would help the venom to spread faster in the body
[Reshma] Ok trying my best
[Hasmukh] Make sure the hospital you go to had Anti Snake Venom. ASV has a limited shelf life. Hence in India only government hospitals keep ASV.
[Shalini] Each country has different species of snakes .. once you get to hospital describe the details
- Area of bite - time of bite - signs and symptoms you are experiencing
- don't consume anything .. no water or liquid or any other thing ..
In most cases snake give dry bites causing irritation and pain .. this can be treated by professional medical practitioner and recovery is faster ..
You will be kept under observation too for next 24-48 hours .. just follow medical advice.. doctors know best to treat this ..
[Reshma] Ok
[Nirav] Is the snake bite area turning dark or any swelling
[Shalini] Dry bites are superficial bites.. nothing to worry much.. there may not be venom injected in these cases ..
Reshma, pls let me know your location and hospital you are visiting .. if any help is needed i will connect you to the correct people who work with anti - venom production folks and researchers ..
[Nirav] Just spoke to her should have reached or reaching in a minute or two
[Reshma] Not dark but a lill swelling is there
On the way...still some minutes I think
Going to the dambulla hospital
[Shalini] Great, just stay relaxed all the way .. you are doing great.. meet the doctor and explain your case .. keep us in the loop
[Reshma] My charge in the battery running out too.. fyi
Sure will do, thanks
[Shalini] Nearest Location .. where in srilanka is this ?
Any other contact number to reach you in the next hour or so ??
[Reshma] Dambulla is a bigger city
[Hasmukh] Give us the contact numbers of the people with you - with area code
[Nirav] Kandy it's a army base hospital so it seems she will get proper treatment
[Reshma, 9:41 PM] In the hospital
[Nirav] Spoke she is ok
Treatment has started
[Shalini] Ok .. thank you
[Hasmukh] 👍🏼Thanks everyone for the prompt action and coordination. @Reshma you are in good safe hands now. Post progress on the group when you can.
[Reshma, 8:06 AM, 12/18/2019] Hi All, I am doing better...there is inflammation of the foot...doctor confirmed that it's not a poisonous snake...checked if the blood is clotting or not..it is clotting hence it's good.

[Reshma, 8:52 PM, 12/29/2019] First and foremost I would like to thank all of you for being such a lovely and responding community...I am overwhelmed with the love and affection I have been receiving...Thank you one and everyone.
The Sapna Ranch group helped me so much in connecting and feeling like I was surrounded with so many loving people virtually, always humbled and feeling blessed.
[Shalini, 9:09 PM, 12/29/2019] Reshma, glad you are fine and all things worked in your favour.  Thank you for sharing the details.
Hump-nosed viper (HNV) is one of the six major snake species in Sri Lanka that cause envenomation. In its natural habitat of the low land wet zone, it is the main snake species that is responsible for envenomating bites.
Note : there is no other treatment for snake bites other than reaching a medical help asap for medical intervention by doctors.  There are lots of hear - say methods but pls find a hospital, meet a doctor for treatment plans. Do not take shortcuts for snake bite ever.. 

​The customer, David Ogilvy warned in 1955, is not a moron, but your wife. Today, the harem is packed with millions and technology has provided a zillion contact points, but do some companies hold on to a moronic mindset?

The bank emailed me that my credit card was eligible for a “premium” upgrade. All I had to do was go to netbanking and “confirm” the upgrade. I started doing that and then aborted when the annual fee field of my “lifetime free” card automatically filled with an amount.
When I got yet another reminder about the “upgrade”, I emailed them for a confirmation that my credit card would remain “free” even after the upgrade. Sifting through the chaff in the reply I received after a couple of days, I found one sentence relevant to me. The upgrade was “subject to” my signing up for a service. And I was asked to call up “phonebanking”.

I wrote back requesting a specific answer—was the upgrade free or not? Received a longer response restating the “subject to” and yet another helpful link to locate my phonebanking number.
I did not ask for the upgrade. You offered it. And are all your bankers too busy or too shy to call me and tell me about the upgrade condition upfront?
Definitely not a wife, I must be a moron to my bank.

Day after day, the range was too poor to make or receive a call. So, I called up customer service. “How many bars can you see?” Huh? Oh, that! I just see a triangle with an exclamation mark. “Where do you face this problem?” At home. “Please give me your address.”
“We are upgrading our towers in your area. Your problem will be resolved by (specific date). Please rate my response.” An email followed that reiterated the same assurance.

When you can anticipate a problem, why wait for the customer to complain? Why not email those who are most likely to be affected? Or at least publish an announcement?
​A few days later, I receive an SMS and an email. “We tried to contact you three times. You were not reachable. The issue is now closed.”
​Doesn’t your inability to reach me validate my persisting problem? Or is it just a good excuse to silence another moron?
The youngster at home advised: “Go to settings and  switch from 4G to 3G.” It worked and still does. The resolution the company promised is yet to materialize.
Huddled in an invisible corner of the harem, I imagine an email: “While we are working to upgrade your 4G service, we request you to switch to 3G so that you can continue to enjoy our uninterrupted service. This is how you can do it ….” That dream helps me hold on to the notion that my husband cares for me.

Sorry, David! They don’t much care for wives now. Could you please advise them to appoint a custodian to mother all customer communications? Even morons respond to sense and sensitivity. All we need is to find a system to fit a mother into the process.

​I drive this cab mostly at night.
That night I picked up this two women from a posh locality in Pune. They looked short on dress and high on alcohol. I would later learn that they were college students.
One sat next to me in front while the other settled at the back. I wonder if it was the AC or the movement of the car that triggered it. Suddenly, the one in front threw up in the car. Almost at the same time, the other one also threw up. Then they were both out. The stink was very bad. And I didn’t want them lolling about.
So, I stopped the car. Used the seat belt to ensure the front one was securely packed. Did the same to the one at the back.
It must have been after midnight when we reached their destination, a hostel. The security guy took one look and refused to let the car enter.
“Show their IDs.”
“It is too late for inmates to be allowed back in.”
I didn’t like the way things were shaping up. Fortunately, there was a police station nearby. I took the car there and explained the situation. In a jiffy, the cops turned the story around. Suddenly, I became the prime suspect. Where did I pick them up from? What did I do to them? After a lot of pleading, they let me go. The women are your responsibility. In case we hear of any rape, we know whom to book.
So, I drove some distance away and stopped the car. There was half a bottle of vodka and pack of Marlboro lying next to one of the girls. I picked up both and locked up the car. Whenever they woke up and tried to open the door, I would know.
I called up my service provider. Explained the situation. Two executives turned up—a woman and a man. When they looked inside, I could see the woman executive trying not to puke. They requested me to stay with the car and the women. They would ensure that I would not land in any trouble. Plus, they promised compensation. Then they left.
I sat a little a distance away, by the road. Finished the vodka and the cigarettes. I thought I deserved that for all the trouble I was in. After some time, the car alarm went off. They were up.
“Are we safe? Where are we?” They were not out of it yet but at least they were conscious. I explained the situation to them and assured them that they were safe. They were very apologetic. Then they asked me to take them to a resort a little distance away.
It was almost morning when they got out of the resort. When they did, they were clutching two bottles of alcohol. Both were drinking all the way back to the hostel.
They got out and again apologized profusely. I said I had suffered a huge loss thanks to them. One of them asked me “how much”. The fare itself was nearly 3,000. Plus, lost business while I was babysitting them. Plus, more potential lost business while the car remained at the garage getting a thorough cleaning. “Maybe about 9 or 10,000,” I suggested. She went to the ATM. Came back and gave me 14,000.
I pleaded with them not to drink so much. They were lucky they were in Pune and not in Delhi. They promised they would take care.
I never met them after that.

I reached the hall a little late. Given that it was the first annual day celebration of “doctor foundation”, I expected to disturb the speech of some important physician, while the other doctors on the dais frowned at the latecomer.
Instead, I found a lovely dance by children in progress, all energy and rhythm. Then came another, where the young choreographer (“a volunteer” the emcee said), was also a participant. Distribution of certificates to those who had completed a beautician’s course (“conducted by an employee”) followed.
As I began to wonder if I was at the right venue, I looked around at the audience. They were mainly children, all dressed for a special occasion. They were restless and happy, with my immediate neighbour bouncing up and down on his seat, enjoying the music. He looked at me as if asking why I was not joining him in the celebration. The lone photographer was having a difficult time protecting his tripod from those constantly running to a  better seat.

Just then, the person who had invited me appeared on the stage. The applause told me she was a favourite of the audience. After all, she was the popular “Bhalla Madam”— Dr. Khurshid Bhalla, Founder Trustee of The Doctor Foundation.

Young Khurshid was always sure she would become a doctor. Her father, the late Maj Gen Dhunjishaw Doctor, had served as the Commanding Officer of a number of military hospitals across the country. That exposure, and her love for children presented paediatrics as a good option. Until a child’s death made her change her mind.
“During my internship, I happened to witness the death of a child who had been admitted to the hospital just four days previously. I was shaken up by that death. To me, it was grossly unfair that such a small child should die, even when he was undergoing treatment in a hospital and the paediatrician on duty was close by,” she remembered.
She turned to gynaecology and obstetrics. “I thought I would be happier dealing with birth. For me, every birth remains a miracle.”
Dr Khurshid Bhalla, now 65, retains her love for children, though she has not helped deliver a baby for several years.
Instead, at the helm of The Doctor Foundation (named after her father), she is today on the threshold of a new era in community care, going beyond medicine. 

She had the option of working with a private hospital or setting up her own clinic. Yet she has spent most of her life working for charitable organizations. Why?
“It is not that I did not try,” Dr Bhalla explained. “I did set up a small clinic in Pune. There I would carefully examine the patients who came, hear them out and then prescribe the test or medicine that they required. I would charge about ten rupees per patient. I thought it was my duty to help the poor and serve them at a price they could afford. I was naive enough to think my model clinic would help a lot of people in the locality. Instead, they simply stopped coming. And my nurse, who was my assistant, told me unless I started giving injections and tablets, no one would come. So, that was that. Obviously, I was not cut out for the business side of care and I could not afford to keep the clinic open.”
In 1996, she joined Care India Medical Society, a trust that provided a social support system in the prevention, early detection and terminal care aspects of cancer management. “Care India’s clinic where I worked was surrounded by homes of the underprivileged. HIV infection was rampant. A few years after I joined, I came across many HIV patients and their families,” Dr Bhalla remembered.
During those years, HIV infection was almost a certain death sentence. Many mothers lost their children; young wives their husbands. “I would visit the women at home and try to help. Some NGOs came forward to adopt some of the orphaned children. There was one shelter in the outskirts of Pune that took in HIV patients. They had zero facilities. Often the watchman, out of compassion, would bring rice and dal from his house to feed the patients.”
It was quite common to simply abandon HIV patients on the streets. “I heard many horror stories of patients curling up on the road all alone. When they vomited or had diarrhoea, they would drag themselves a little away from the filth, helpless and miserable. I knew this was cruel reality and not just fiction, when I heard a social worker casually announcing how she had abandoned her husband, who was in the final stages of AIDS,  outside their house before she came to work.”

As part of Care India’s work, Dr Bhalla used to visit Yerwada jail in Pune to examine women inmates. “The jail authorities were surprised that I mingled closely with the women. For me, they were simply human beings who needed care. Some of them were overcome because someone from ‘outside’ was willing to touch them, talk to them.”
Dr Bhalla was shocked to learn that some of the HIV-infected prisoners, whose terms were over, refused to leave the jail. They would plead to remain in  prison. “Where else would we go? Our families do not want us.” One ex-inmate settled under a tree a little away from the prison. The police decided to force the issue and took him to his house and browbeat the family into accepting him. After all, he was the owner of the house. That didn’t work. The next day he was back under the tree.

Then Dr Bhalla got an opportunity to extend her work in HIV. In 2004, she joined Mukta, set up by Pathfinder International, funded by Bill & Melinda Gates Foundation. She started work in Budhwar Peth, where most of Pune’s sex workers continue to live and work. “There were about 3,800 women living within one km radius. Initially as I tried to connect to them, I understood that they had the same story—mouths to feed. And as they put it, ‘after the first time, it gets easier.’”
They did not want to be tested for HIV. “What’s the point?” they would ask me. “If we have the disease, we are going to die, test or no test. We would rather die without knowing.” It took a long time for things to improve. Things eased once antiretroviral therapy (ART) arrived on the scene. HIV infection was no longer a death sentence.
Dr Bhalla considers the 10 years with Mukta a great learning experience in helping the community scientifically. “We had some of the best trainers working with us. For the first time, I found myself hopping into a bus and travelling to unknown villages to set up a network of clinics. I never considered myself a teacher. That stint taught me to be a trainer, to work with a team, to share the commitment so that more people could benefit.”
After Mukta, Dr Bhalla returned to head the charitable chemotherapy unit of Care India Medical Society for a few years.

When it comes to palliative care, the norm is “detached attachment”. You should be fully attached when you are there with the patient, but detach yourself later. This ensures you don’t carry a baggage of interminable worries, fears and sorrows home.
“I know that I am a softie. But I can’t help being fully attached to my patient. Yes, I have been a victim of compassion fatigue more than once. But that’s who I am. I always say that I have more friends up there (in the heavens) than down here,” Dr Bhalla confesses.
A 10-year old boy with cancer of the bone was Dr Bhalla’s patient when she was at Care India. He was the only son of a mother with three daughters. Once the doctors were discussing his case with the mother. After all the tests, they had concluded that the only option was to amputate the affected arm. They announced this to the mother. “They ignored the boy who was in the room with them. As soon as he heard the verdict, he jumped up and ran out, screaming. I was very upset. That was not the way to break the news. They treated the boy as if he didn’t exist. I was determined to make amends,” Dr Bhalla remembered.
Despite warnings from her senior, she took personal responsibility for the child. “If he were my son,” Dr Bhalla told his mother, “I would try to save the arm.”
​She took the boy to Tata Memorial Hospital in Mumbai. There she found that there was a procedure to excise the affected portion and spare the arm. With the mother’s permission, Dr Bhalla got the surgery done in Pune.
“I felt vindicated. The family was happy. But the joy did not last too long. The cancer returned. The boy was in severe pain. Then he died,” Dr Bhalla was distressed to recollect the case. “Finally, I understood why my boss was cautious. There had been a similar case where they had opted for the amputation. That boy was now doing well and was a regular participant in the NGO’s cultural programmes. It was a painful but necessary lesson. You must be compassionate, but being emotional can cloud your judgment.”
Dr Bhalla regrets that compassion is largely missing today. “When my father was dying of cancer, several doctors were treating him and would come to meet him every day. He always looked forward to these meetings. Then they stopped coming. He would often ask us why they hadn’t come. Finally, the truth dawned. There was no treatment left for my father. What would they tell him? It was perhaps embarrassing to tell him that there was nothing more they could do. Looking back, I think even I failed my father as a doctor. Like the others, at that time I too did not know how to talk of death.” 

It is 2 a.m. The family has gathered around the bed of the dying elder. It is clear the end is near. The family has been prepared. Nevertheless, a call is made. After putting the phone away, Dr Bhalla gets ready quickly. Her scooter takes her to the house through empty streets, where “the stray dogs are my only companions”. She arrives and peace descends. She sits with the family until the end. She checks the patient one last time, leaves whispered instructions, consoles the family and goes back home.
“This is something I have been doing for a long time. Many of my patients are the elderly or terminal. I spend time with them and the family. It is a privilege to be with them during the last moments. Nothing happens medically; a lot happens emotionally.” Is this a service under The Doctor Foundation? “Yes, it falls under my free home visits,” Dr Bhalla said.
Walk into the Foundation’s clinic at Bhawani Peth in the evening and you are likely to encounter boys and girls learning to dance, young women learning to be beauticians, a tuition class and a couple of sewing machines that used to train would-be tailors until recently. Aren’t these rather strange engagements for The Doctor Foundation, headed by a medical doctor?

“The Doctor Foundation’s objectives are rather broad, but the main goal is medical care,” Dr Bhalla explained. “We were registered in 2013 and started out with home visits in 2015. We started this clinic in 2016 and opened another in Kondhwa (another locality in Pune) in 2017. I am fortunate to have a team of doctors, mainly specialists, offering their services at the clinic on different days. The idea is to offer professional medical service at a nominal cost. Why should the poor be denied the service of a medical specialist just because they cannot afford it?”
And the dancing children?
“My original idea was a care and community centre for the elderly. We ended up attracting more children from the neighbourhood. In any case, once we finished with the patients during the day, the entire space was available. Why not put it to use?
“An NGO donated sewing machines to teach the women in the community. Somehow, tailoring seems to have fallen out of favour, and so the machines are now idle. Then we had a part-time choreographer come in, keen to teach the boys and girls dancing. He is a big hit now! We also had an employee who was already qualified, volunteering to conduct a beautician’s course. Then a couple who takes tuitions free of cost for poor children asked me if they could conduct their classes here. So, we have a lot of young people coming to the clinic and, in my view, that really energizes the place,” Dr Bhalla said.
That explained the dance performances I saw at the annual day celebration. “I thought it was a great opportunity for the children to showcase their talent. The money for hiring the hall was donated by a well-wisher. In fact, the Foundation has not spent on a single piece of furniture you see here. Some came from my house; others are kind gifts from various people. I prefer to spend only on essential overheads. The rest is all for the patients,” Dr Bhalla was very clear.

So far, Dr Bhalla and her team of visiting specialists have cared for more than 5,000 patients across the two clinics. She is very keen that the Foundation does more.
Her wish list for The Doctor Foundation has three main items. 
Set up a network of partner clinics. She wants to identify clinics that provide ethical, efficient service to patients and make them Preferred Partners of the Foundation. “I would like to begin with Pune and then spread to other districts.”
Improve the home care programme. Recruit the minimum essential team and train them. “I have a couple of old cars lying around. I will be happy to begin with those.”
Set up a hybrid home. “It will be a home for the elderly to begin with. Then I would like to add on an orphanage for children. I think the young and the old will provide each other very healthy company. It will be a happy home for both. They will not be just put there; they will want to be there.”
Would the plans be commercially viable? “I am counting on cross-subsidization. Those who can afford to pay will get better facilities. In the process they will help us serve more poor patients. The service quality will be the same.” Dr Bhalla is positive her dreams would come true.
Dr Bhalla is grateful to her fellow trustees for helping her set up The Doctor Foundation. “It has given my life purpose. I have a good reason to wake up every morning.” She also thanks her fellow doctors, the specialists who spare the time for The Doctor Foundation. “It is hardly remunerative for them. But they do it in the spirit of giving back.”
Several hundred beneficiaries may not understand the intricacies of a trust. They are simply grateful that Bhalla Madam will hear them out and tell them what is wrong with them. They know she is on their side. And she always has the time to sit with them and hold their hand.

The Guardian recently reported a study that found “the brain shields us from existential fear by categorising death as an unfortunate event that only befalls other people”. In other words, we are wired to deny life's only certainty, death.
That being the case, it can be difficult to document our preferences about death. How can we think and discuss about how we want to be treated (or not) should we reach a terminal stage, a point of no return? But, think we ought to. Discuss we should. Document we must.
The Supreme Court of India gave legal sanction to this “advance medical directive” or “living will” on March 9, 2018. The Supreme Court ruled that “in specific circumstances, a person has the right to decide against artificial life support by creating a living will,” and that “the right to life and liberty, enshrined under Article 21 of the Indian Constitution, also includes the right to die peacefully and with dignity.”
Delivering the judgment,  Chief Justice Dipak Mishra observed: “Should we not allow them to cross the door and meet death with dignity? For some, even their death could be a moment of celebration.”

​Despite the ruling by the apex court, a living will remains a touchy issue. In 2015, three national medical associations of neurologists, intensivists and palliative care physicians came together to form the End of Life Care in India Task force (ELICIT). Dr Roop Gursahani, a consulting neurologist, who is part of ELICIT, says we “need to make conversations about death natural and not forced”. He points out that a living will “takes care of one’s healthcare decisions at the end of life."
While living will formats can be easily downloaded from several sources (here is one), the government is yet to translate the Supreme Court ruling into enforceable procedures. Some experts feel what the court has suggested is too restrictive. You need to be certified terminally ill first, which may be too late. Also, the will needs to be countersigned by a judicial magistrate first class, who is not within easy reach of most people.   
Nevertheless, it is prudent to make a living will and communicate your preferences to your loved ones and those responsible for your health care. As it is difficult to plan for every eventuality, you can leave it to the discretion of one or two people whom you trust to implement your will. 

​Mention “will”, and one tends to think of a very legal-looking document. And of lawyers, and members of the family throwing not-necessarily friendly looks at one another. You also think of someone very ill, unlikely to be helped by all that he (or she) owns and has willed it away for others to enjoy.
What matters most at the end is peace and dignity, at least for the patient. However, there is no wishing away the money elephant in the room.
Fortunately, compared to the ethical and medical issues, planning for financial security is easier, provided you are willing to start long before it is time to make that final transition.  

​Q: Whether you wish to try everything possible to prolong life or decline heroic medical interventions, there are financial implications either way. How does one tackle this?
Sneha: Life is a very delicate topic. My life is more precious to my near and dear ones than I perceive it to be. And this is often observed when a family member has to decide about treatment at the end of a loved one's life. These decisions are emotionally and financially draining if we do not know what the patient wants.
You can help your family by having three things in place:

1. Life insurance along with health, critical illness and personal accident cover, when you are still working and earning.
2. A separate fund for medical treatment at the time of your retirement. This will ensure that your family is not put under pressure when you are beyond insurance cover.   
3. A living will that will make end-stage decisions easy for your family caregivers, without getting into ethical tangles. 

 
You help clients plan their life goals after retirement. Do you talk of terminal illness? Is it possible to quantify this requirement?
Like I said, from the financial planning point of view, everyone should have the four basic insurance policies in place. However, as it keeps on increasing with one’s age, paying health insurance premium would be difficult after retirement. Additionally, medical inflation (cost of medical care) is presently the highest at 12% per annum. This is the reason why we need a separate medical corpus for the post-retirement period.
When I speak to clients on retirement, I start by understanding their expectations. Many are practical. Some I need to sensitize about age-related illnesses. How much would they value their financial freedom should such a situation arise? 
The value of the corpus would depend on the individual and family, their standard of living, cash flow, net worth in the pre-retirement period, etc.
 
These days parents prefer not to burden their children with end-of-life care. Do you have that conversation with the parent(s) or the children or both?
Today, most parents are self-sufficient. However, they do need help in case of a medical emergency. Those who are still earning and want to be self-sufficient can build up a buffer for these emergencies. When I begin my conversations with parents, I try to understand where they stand in the Maslow hierarchy. 

When I know it is the right time to speak about legacy and wealth migration, I chart out detailed sessions with the parents first and then their children. During these sessions I speak not only about estate planning, but also about palliative care, end-of-life treatment and living will. Once the parents understand all this and are confident enough to talk about it, I involve the children.
However, in spite of the Supreme Court ruling, the legal status and practical applicability of the living will remain hazy. Therefore, I tell my clients they should consult their doctors and lawyers about this.

One son abroad is fully bearing the cost of treatment. The second son in India is the 24-hour caregiver but has no money. They have conflicting views on what is best for the patient, their father. How do you tackle such a situation?
In this scenario of transition, both the sons are in what we call the anticipation stage. You expect an event (end of father’s life) to occur but that has not yet happened. Both the sons portray struggle traits in their behaviour. The one abroad is probably feeling helpless as he cannot be present physically. The other one is experiencing emotional fatigue, where he cannot see his father suffering in front of his own eyes. As a financial transitionist, I would use certain tools to help them clear their fears and frustrations. Then help them arrive at a decision that both are happy with and is best for the father, too.
 
If one has drawn up clear plans after discussions, how to ensure those are enforced when the patient is totally helpless? For example, the patient may expect a certain course of action but the spouse may act entirely differently.
I cannot speak on the legal position, but some of the issues here are that of understanding and expectation. Generally, financial planners/advisors talk about goals because they’re trained to craft them, and create timelines and benchmarks.
Expectations are the spaces that exist in the narrative about goals. Some are vague, some are small, and some are fleeting. Regardless, they’re all important because they influence the thoughts and behaviour of the client. What makes expectations complicated is that they’re frequently not verbalized. Someone may or may not be correct about their perception of the expectations of others, even their near and dear ones. Regardless, expectations can create an unseen but powerful undercurrent that influences relationships, behaviour and satisfaction.
When left unexplained while making important decisions, those details become little spaces of uncertainty that could create financial and personal problems. I help clients write down their assumptions and expectations regarding an event yet to occur. I also discuss the time horizons to gain greater clarity about why they have these expectations. Based on similarities and differences, I help determine the next steps most relevant to them. It could involve separate one-on-one discussions or joint sessions.
This helps verbalize the thoughts and expectations one has of the other and brings the differences to light. Then it becomes easier to work towards a common ground.
 
When is the right time to talk of the living will?  
Again, when I introduce this topic would depend on my comfort level with the client, his or her age, life circumstances, background and standard of living.  For example, if I’m talking to a just-married couple, I will have to be rather sensitive about broaching the subject of a medical corpus. However, if either or both of them have already had close encounters of the medical kind involving someone close, they would be already sensitized. It would be easier to talk about medical corpus, end-of-life treatment and living will.

In your opinion, what can be done to minimize confusion and ensure dignity at the end of life?
Just to sum up, five actions can help a lot:

1. Maintain the required Insurance covers.
2. Build up a medical corpus.
3. Prepare a living will.
4. Manage expectations during the anticipation phase of transition.
5. Review the financial plan to be clear about the financial backing available.

It would be wonderful to work in tandem with the family doctor, the lawyer and the executor of the will. That will help nip most confusion in the bud. However, I would take this call based on the comfort level I have with the client and the time we have spent together. 

Have another question? Ask Sneha Jaggar. ​

It was February. I stood barefoot on the beach, watching the waves rise and fall mightily, roll over my feet gently and then immediately return to meet the vast ocean. The evening sun spread its colours across the sky. Tiny boats dotted the horizon, returning to the shore. The smell of the sea filled my nostrils.
I wondered how this came to be my life. How did I end up giving birth, then losing my 4-year-old daughter to cancer (brain tumour) after 18 months of struggle (of which 14 months were in palliative care)? How did my family and I survive the trauma?
How did I come to stand on this beach without Ira? 

I had noticed minor tremors in Ira’s left hand in March 2017. Initially it was attributed to motor development issues. After a few visits to the paediatrician and the neurologist, and a scan later, the diagnosis was confirmed—thalamic glioma.
A surgery was imperative as the tumour pressed on several parts of the brain. All through, from diagnosis to surgery to post-surgery, hope remained a constant but its face kept changing. From hoping that the tremors would be non-worrisome, to thinking that the surgery would have no complications and to assuming that we’d be back home in 15 days. Ira’s treatment in the hospital lasted for 2.5 months.
A major brain surgery and several post-operative complications later, Ira was in a state of poor consciousness. She had lost her speech and her ability to register and respond to stimuli around. In medical terminology, she was in a vegetative state. With each passing day, hopes of her recovery diminished. Our hopes for cure and recovery changed to hopes for comfort and relief for Ira.

As a mother who went through it, I think there is confusion about hope during palliative care. It is not about giving and keeping false hopes about recovery or cure. Although, in our case, the acceptance of Ira’s condition took time to settle in, we learnt to keep any false hopes about her recovery at bay.
We need to understand and accept the prognosis and course of treatment. There is no need to dismiss or discard hope. It just needs to be realistic. Focus on short-term goals and expect practical outcomes. Right through her palliative care, with all our love and compassion, we worked to provide as much comfort at home and as much relief from her neurological problems as possible.
If a terminal patient or family member makes long-term plans or envisions a future with all, it is important for the medical and allied professionals to gently help them understand the prognosis. And tell them what hopes that they can realistically harbour. 

Hope in palliative care, as complex as it may appear, is about several aspects except a cure. It should be about a good quality of life in the time left, reconciliation and closure with family members and friends, avoiding discomfort during the care, and being cared for with utmost love and selflessness.
Though the tragedy of loss and the grief of death always stared us in the face, our family was content that distressing symptoms were reduced and managed at the earliest. As her mother and caregiver, I felt that Ira’s troubles, malaise and anguish were far greater than mine, and this gave me the strength to keep going and to care for her with even more compassion and love.
Yes, hope is intangible. It will not just bounce into your life and light it up like fireflies at night. Find it within. Hang on to its threads as if your life depends on it, because it really does.  

Pratima Mehta writes a blog about Ira’s journey, how the family coped and practical aspects of care.

​I started looking after Madhav following a phone call.
“Can you help my mom? My father is a dementia patient. My sister and I live out of India. My mother has difficulty managing him. Can you make home visits?”
With Eknath too, the starting point was a call. However, the caller was clueless about the diagnosis.
“Can you help my uncle?” Sure! What sort of help? “I don’t know. I need your guidance.”

Both Madhav and his wife have chronic medical conditions. He has dementia and heart issues. She has kidney problems, diabetes and blood pressure.
Their daughters who live abroad try to manage things remotely. There is no other family support.
The first thing the wife told me was, “He does not remember anything, does not want to do anything and doesn’t co-operate. I don’t understand why he is doing all this to me. Why can’t he just behave properly? He was okay until a few months back.”
“You do know that he has dementia, right?” I tried to make that question sound as gentle as possible.
“Yes, I know that. That is okay. What about the other things he keeps doing that trouble me?”

Eknath is unmarried. He was a professor in a small town, lived alone, self-sufficient. He has always been on good terms with his siblings and their children. No longer working, he was keen to spend the rest of his life in that small town that had been his home for so long. But fate had other plans for him.
Worried by his repeated falls at home, his neighbours requested his nieces and nephews to take him to a place closer to them. Thus, after 40 years, he ended up in the big city of Pune.
Investigations suggested the beginning of Parkinson’s. One of his nieces volunteered to accommodate him in her house. But he was not comfortable there. He did not want to be an extra burden as his brother was already a Parkinson’s patient and needed constant attention.
Eknath became aloof and would not co-operate. They decided to let him to stay separately, with someone visiting him frequently.  This arrangement lasted for a few months. However, as his symptoms worsened, it became difficult. 
When I visited him, his cognitive abilities were intact, he could recognise people and he was alert.

In another part of Pune, as I started working with Madhav, I realised that many of his cognitive abilities were affected. He could not comprehend what he was reading, nor could he complete any activity on his own. But I decided to make the wife my first priority.
We had a few issues in the beginning, but I managed to develop a good rapport with her by and by. I had to make her understand the whole spectrum of dementia and how to cope with his behaviour.
In the course of our conversations, I discovered that apart from watching TV and playing solitaire on the laptop,  she could draw well and liked to solve word puzzles.
She did have some drawing material lying around but those were in a bad shape. She was not very keen to spend on her hobby, but I persuaded her to get some new stuff and arranged for some puzzles. Soon, she got going and was happy in her own space.  

In the case of Eknath, it took some coaxing before Eknath agreed to employ a caregiver for the day. “I don’t want anybody in the house, I can manage myself,” he was still the proud, independent professor.
Eknath had not been to a doctor for more than two years. I suggested a visit to the neurologist. Tests confirmed early dementia. Marking a new phase in his life, Eknath started taking medicines and slowly got used to the caregiver.
There were more falls and serious issues with hygiene and nutrition. The caregiver had to start staying nights, too. “This is an invasion on my privacy,” Eknath protested. We were all helpless. We pleaded with him to try it out for a few days. He agreed reluctantly.
I helped set some rules and regulations for the caregiver, who had had no professional training. I also used my weekly visits to build a good rapport with Eknath. We would do a lot of activities together—games, puzzles, drawing, painting, craft work and so on.
They all cared for him, but the nieces and nephews could not spare too much time from their respective lives. Except for his siblings and some old students, he had no social visitors.
Life appeared to be under control. 

Meanwhile, Madhav  was having his good days and bad days. Did they have any doctor on call to help them out, in case …. No! Any relative? “Well, I have a cousin. She is old. But she can come when needed.” That did not sound very promising.
I was constantly in touch with Madhav’s daughters. They arranged for a local doctor to come home and guide them. We also managed to locate a younger member of the extended family, who was willing to come whenever Mrs Madhav needed any help. I gave them a few tips on making optimum use of the support system now in place. When to call for the doctor, when to hospitalise, how to manage the caregiver and so on.
I helped them prepare their home for the long-time care of a dementia patient—caregivers, Fowler bed, essential medicines. I also got them to involve a step-down centre where he could be admitted for symptom management. They also engaged a palliative care physician. I involved the family in long discussions with the experts—what to expect, likely difficulties and how to manage those.
“How do you want your father to be cared for?” I asked both the daughters.
“Do everything possible,” one said.  “I want him comfortable,” said the other. Two different perspectives. As it happens very often, I knew this conversation would be long and slow.
“Where do you want your father to be? At home or in a hospital?”
“Home, of course.” Mother can manage him best at home.
Initially, the daughters were unsure about involving the mother in the discussions. What would she know? Well, she surprised everyone. During the discussion with the palliative care specialist, Mrs Madhav clearly demonstrated she was now assessing the situation objectively and was ready to cope with comfort care. Both the daughters also concurred that comfort and quality of life were important.
All these discussions got the daughters worried.
“Is father so ill? Should we come down to see him? We want to be there when he is really bad and when mother needs us most,” they told me.
“I understand that,” I told them. “But how about coming now? When your father can still recognise you? You can spend quality time your parents. You will always cherish those memories, whatever the future holds.”

One day, Eknath had a nasty fall. That necessitated a surgery followed by another. Old difficulties like incontinence, hygiene problems and behavioural issues started worsening. A local doctor was arranged to take care of his physical symptoms .
Meanwhile, the need to provide constant care day and night took a toll on the caregiver. He suffered a burnout and the quality of care dropped. It was time to look for a more lasting solution. That triggered a debate among the members of the family.
“Why not keep him in an assisted-living centre? He will be well cared for.”
“But for how long?”
“Maybe he should move back to his hometown? That’s what he wants.”
The discussions went on until they decided to keep him in a centre under medical supervision. 

The journey continues. Madhav’s daughters have already come home more than once and have spent time with father. As he continues to move away from them in body and spirit, they are more in control of what is happening.  Mother and daughters are more at peace.
At the centre, Eknath’s health has improved slightly. They have started him on physiotherapy. There are people around he can interact with. At the request of the family, I have been regularly visiting him at the centre. He repeats one question, “When do I go home?” Are you not comfortable here? “Yes, I am. But I want to go home.”
Eknath’s family and well-wishers are still discussing. There are some tough decisions to take. Everyone means well. Everyone wants a say.

When I met her the first time, she was on a wheelchair, in severe pain and was being treated for pancreatic cancer for nearly three years. Her husband, her primary caregiver, was with her.
I studied her papers and examined her. I asked her if her ascites (fluid in the abdomen) was causing her discomfort. She was willing to manage.
The next contact was about 12 days later, when the husband called. She had been recommended an MRI. He asked me if it made sense to push her through yet another MRI. Then he came over to talk to me .
Their two sons were abroad. Financially, they were comfortable. They lived on the fourth floor and the building had no lift. Every hospital visit meant maneuvering her down the stairs. He was willing to do that. But to do that every time? Won’t it be difficult for him to manage her at home?

I briefed him about the potential challenges of at-home care. Perhaps it was time for him to have a frank conversation with her doctor about the prognosis?
One week later I got a request to visit the patient at home. The doctor had said that her treatment was now at a palliative phase. Thanks to that, the husband had a better idea of my role as a palliative care doctor.
I examined the patient. It was obvious that her disease was progressing rapidly. She looked jaundiced. No, she still did not want her ascites to be drained. She looked at peace, pretty even.
She had just one fear. Occasionally, when she got up, she felt as if she was about to fall. Now that I was with her, I encouraged her to try and get up. With my help, she did.
She was stumbling. It was clear to me that she was wobbly. After safely putting her back in bed, I suggested several measures. She was not to be allowed to get up and walk without support. Never. And she needed a hospital bed with rail guards.
His brother walked with me as I took the stairs down. He was not sure if the sons had the correct picture. I suggested he could share my number with one of them and I would be happy to brief them. He was relieved.
That evening, before I could speak to the son, I got a call from the brother. The patient had had a fall. They had rushed her to the ICU in a nearby hospital.

While the immediate injury was being taken care of at the hospital, I got a call from the son in the US. I briefed him fully and answered his questions. He said he was coming to India towards the end of the month, three weeks away. If he wanted to spend some quality time with his mother, I suggested he should reach sooner.
The next call I received was again from the same son but after he had reached the hospital in Pune. He had met his mother and she had recognized him, smiled at him. He was happy.
A couple of days later, the husband’s brother called again. She was not doing well at all. The second son too was on his way.
He too got to meet mother, but she was already on ventilator. The family had a discussion with the doctor. How long should she remain on the ventilator? The sons decided to wait until the next evening.
But she did not wait. She passed away the next morning, in the ICU. 

A few days later, the son spoke to me.
“We knew her disease was serious. She was so keen to be at home. Dad was trying to make it possible. I desperately wanted her to get comfort care, like what we get in the US. Then after all those months of suffering, she got to meet you. Thank you for asking me to come down sooner than I was planning to. I got to meet her, spend some time with her.” He was sobbing bitterly.
I told him that all I did was try to make the journey smooth. For the traveler and her dear ones who were around to see her off. She was gone. But those moments together, those memories would stay.    
When it comes to a terminal condition, is it possible to prognosticate the end with any certainty? Would the ending have been less painful for all, had there been franker conversations sooner? Could they have then made better use of the time with her?