Recently, I was asked to review a patient admitted in the NeuroICU, and the information conveyed to me was that the patient’s family had requested consideration of admission under palliative care. This was a setting ripe with a multitude of challenges – legal, ethical and moral and tinged with a newness – of entering a proverbial hitherto unexplored minefield, ripe with legal uncertainty.

A review of the situation gave rise to the following observations – A Geriatric patient with fronto-temporo-parietal subdural bleed, which was recently evacuated, with multiple comorbidities, has had a poorer than expected period of recovery, characterized by recurrent seizures and hyponatremia. She had been intubated due to a poor neurological status (GCS less than 8), and the anaesthesia team was finding it particularly difficult to extubate. They had been in discussions with the family who were hesitant to consent for a tracheostomy. The family had been finding it exceedingly difficult to come to terms with the guarded prognosis or the unfortunate turn of events and required someone who could understand their concerns.

My first response was unequivocal, that this wasn’t the time for admission, that the patient deserved management of ongoing medical issues and that in the event of a step down, if it were to take place, the HDU would be the preferred place. In fact admission under the medical ward with consultation liaison with palliative medicine, who could continue to assist the family in making ethically and morally complex decisions and offer an insight into the existing legal stipulations were expected to be key.

During my first meeting with the family, I was able to make the following points – that I understood the family’s predicament and empathized with their situation. That their frustration with their having been no improvement in the patient’ general condition after almost a week of ICU admission was somewhat understandable. And that uncertainty was a real consideration. And that accurate determination of prognosis in this situation was exceedingly difficult. However there was near unanimity on poor functional outcomes. That the patient in front of us, would not be able to lead an independent existence. My discussion with them also involved counselling them about the need for a tracheostomy, and that there might be a requirement for supplemental oxygen along with ongoing intensive nursing requirements. I also discussed the specific difficulties with de-escalation of treatment, and that Supreme court judgements had been unclear on the mandate for the palliative physician. Guidelines suggested the formation of a panel of experts and an observation period (of upto 30 days) prior to allowing withdrawal of treatment. The family welcomed my involvement, respected my commitment and advised me to be a part of the subsequent meeting.

The next meeting which involved other members of the multidisciplinary team including the neurosurgeon, neuro anaesthesiologist along with me, consisted of a discussion of history, course of the patient in the ICU and reiteration of challenges, was punctuated by a very sudden and request for non-escalation to the ICU and DNACPR by a member of the patient’s entourage with a medical background. The anesthetist did not embark on an acknowledgement and perhaps due to my first time participating, I was hesitant to advocate on behalf of the incapacitated patient. I re-iterated the points that I had made earlier, but it did not escape me that I had witnessed the family members attempt to elicit a response from the patient at their bedside. This was seemingly at odds with the request that they had just made. I discussed this with a medical social worker who has been associated with the services and the fact that this was not in fact a patient with an irreversible, life limiting illness was confirmed. Looking back at the trajectory of her illness, she had suffered a rapidly progressive decline and was now E4, V5 on GCS.

What were the family’s motivations for this request? Had this been a tacit acknowledgement of the patient’s expressed wishes or was there something that had been lost in translation? What forced the Palliative specialist in me to sense a feeling of discomfort? What are the legal coordinates in this scenario? Was there a need to advocate on behalf of the patient? Was it too early to consider transfer to palliative care?

The family provided their consent for a tracheostomy, her CT scan demonstrated neurological status-quo and she was re-started on antibiotics. The uncertainty about prognosis continues to remain. Will there be an acute event or will her trajectory allow for de-escalation? Only time will tell.

It dawned on me soon enough, Whatever the outcome, this palliatrist needs to be better prepared to speak on behalf of the patient in the future.

Cite as – Arora, R. D. (2026). Mindful critique (MC10): Bend around the curve — An unexpected request for de-escalation and DNACPR. To what extent should a palliatrist be prepared to advocate on the patient’s behalf?. Zenodo. https://doi.org/10.5281/zenodo.21258836

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.

Palliative medicine is a relatively young subspecialty whose intellectual and clinical boundaries continue to evolve. In the absence of definitive texts to address contemporary questions, artificial intelligence tools, primarily Claude (Anthropic), have been employed to challenge assumptions, support deeper conceptual exploration, and improve clarity of expression. They do not replace critical scholarship, clinical experience, or editorial judgment. Final responsibility for all interpretations, factual accuracy, originality of synthesis, and the quality of the published material rests entirely with the Founder and Editor.

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