While training to become the third postgraduate in the country to secure the MD Palliative medicine qualification, the terminology goals of care or the term ceiling of care never became a part of my working vocabulary. Perhaps this had a lot to do with the absence of postgraduate beds during that time, rather than my absence of interest in pursuing palliative care. While I was given the chance to admit patients and manage medical issues, supervised ward rounds never became a daily fixture.

Imagine my surprise, when I came across an archaic ceiling of care document during my training as the first (yet again!!) senior resident at another organizational behemoth with dedicated beds. But imagine my horror, when I was made aware that instead of focusing on medical issues, ethical intricacies or the responsibilities that come along with taking charge of the care of a patient, the focus was to be put squarely on pain management (often at the cost of everything else). That I was to become used to the computer generated algorithm being perpetuated around me and that this basic question, of what do to when the patient’s condition deteriorates was to be relegated to the dustbin of obscurity, was never stated but regularly implied.

The term ceiling of care was first introduced in my vocabulary while I resumed working as a registrar in the middle-east, where the medical oncologist’s supervision of ongoing care delivery was most dominant, and again as a senior medical officer in Brunei Darussalam, an experience that has most singularly shaped, the specialist that I have become. In that the backbone that integration with Internal medicine, provides to the skeleton of a fledgling palliative care service became most evident here.

As a faculty, it has also been an uphill ideological battle trying to justify admitting patients in my unit, where I am supposed to take sole responsibility for their care while being aware of the severe limitation of resources. Can I even begin to fathom surpassing the flaws inherent in the organizational rhetoric of the system?

I have tried to modify the existing ceiling of care document (labelled as the DNACPR form), but a lack of transparency, where any attempt at enabling an autonomous decision is met with silent indifference seemed to have halted any real momentum.

And moreover, the construct of the Intensive Care Unit has been absent from the picture since the time of my joining. There have been no medical ICU facilities in a tertiary care cancer centre for the past two years. Period. That also means that there is no code blue. Yes that is correct, any person who suffers from a cardiopulmonary arrest at any stage in their illness, dies. Period.

How does this affect the validity of the ceiling of care form in the Palliative medicine ward? Am I actually giving my patients a choice, or am I forcing a decision upon them? For the underprivileged, their deal seems to be – either get admitted under the existing ceiling of maximal ward based care or search for another tertiary care hospital willing to save your advanced cancer patient’s life. Does that sound fair? Can the palliative ideology justify this act of coercion by absence?

Having faced repeated rejection by interview panels affiliated with this narrative, without justification offered, I find myself staring into the same abyss as my patients. Is the elimination of a viable alternative the defining tactic of a well-rehearsed systemic machinery — whether the subject is an underprivileged patient or an inconvenient specialist? I recognise in their coercion the shape of my own. We are, it seems, confined by the same absence and bound by the shared understanding of it. Their anguished concern at my imminent departure seems completely justified.

Disclaimer – Every attempt has been made to safeguard the identity of patients referred to in the vignettes and any circumstances arising out of this moral treatise are completely unintended on the part of the author. The author does not intend to cause any harm to another individual’s or organization’s reputation and has tried his level best to ensure that identities are fiercely protected.