A review was recently sought for a patient with stage 3 Lung cancer, with history of recent receipt of immunotherapy, admitted with neutropenic sepsis in the medical ICU. I was told that the patient’s wife seemed unaware of the poor prognosis. I discussed with the admitting consultant whose resident outlined the situation to me thus, that they were waiting for the antibiotics to take effect and had been able to down titrate the noradrenaline from 10 ml/hr to 5 ml/hr. She also added that the family had decided to forego intubation and mechanical ventilation. I discussed the counts, enquired about the baseline procalcitonin, sepsis work-up, noted the creatinine clearance, raised BNP and proceeded to talk to the wife in the presence of an interpreter. I was met with a staggering amount of incomprehension, the wife refused to answer any query about her understanding of the situation. Every question which was meant to understand her level of comprehension about of the gravity of the situation was met with a statement referring to the fact that she had been informed that the patient was to be shifted to the ward. Soon, flustered and overwhelmed, she appeared to thank me and left the patient’s bedside.

I explained my reading of the situation to the interpreter – given the unwillingness of the relative to participate in the discussion, there was no way to confirm that she was aware of the full repercussion or implications of the documents that she had just signed. But did my duty, to keep the patient comfortable, also not extend to the family. Was I also not to respect the fact that a wife who was too overwhelmed to comprehend the immensity of the situation, had taken the decision that she would not let anyone broach the subject of her husband’s impending demise. That she did not want to discuss this unpleasant situation, period.

I took one look at the patient who appeared calm and proceeded to document that I like the resident at the bedside was not sure about the irreversibility of the condition. That one needed to wait and watch for the response. My inference was bolstered by the fact that a urine output of 1300 ml had been recorded (as against an input of 1200 ml). My eye suddenly caught sight of a p H of 7 on the ABG, and I was distraught. Did my assessment of the situation deserve a review? In these situations of doubt, one needs to go back to the bedside, and my fears about a poor prognosis and imminent decline were confirmed when I realized that the patient who had been sitting a few moments ago, was now breathing in a rapid, shallow manner, manifesting the severe metabolic acidosis.

I documented issues where I could possibly intervene, that there was no noisy breathing and the treating team was to contact me in the event of any decision to de-escalate treatment. But the irony did not leave me, that despite the presence of a palliatrist at the bedside, there were no provisions in place to formally de-escalate treatment. I could advise de-escalation in a patient whose relative had signed DNI (do not intubate), but it would not be carried out in seconds. Perhaps a more robust discussion with the team could have sufficed, but we (the intensivist and me) had only been able to come to the conclusion that the patient was not expected to survive the night.

Was the opinion of two specialist doctors enough to constitute a legally valid instruction for de-escalation of treatment? And how was this to proceed?

Would he survive another hour for a re-evaluation? Would he survive till morning, when another male relative who was not averse to this line of communication could appear?

How heavy was the logistical burden that the family was being subject to, in addition to their cognitive overload?

Was I supposed to bear it?

Was I prepared to bear it?

Though I have de-escalated antibiotics earlier, I have never downtitrated inotropes in the ICU, physiologically it does not appear sensible to me to expect a patient with septic shock to survive beyond a mostly abbreviated period, if withdrawal was undertaken. Was there a protocol in place? No. I have heard of instances where patients have been extubated and shifted to their homes on a portable CPAP device with supplemental oxygen, honouring their preference to die at home. But in another country.

What purpose had I served by providing a bedside consult. I returned to re-review and unsurprisingly enough, the patient was gone. The wife stood stoically at the counter discussing the specifics of extricating his mortal remains from the ICU. Along with her male relative, who I had planned to discuss things with in the future. Did this lack of interference aid her? Can I label this common sense as masterly inactivity?

I have also heard the word gasping being said out loud both times while exiting from the ICU.

How many families prolong their suffering and opt for patients to keep receiving expensive, life-sustaining treatment till the time of their death?

Harish Rana, who was outside the ICU, was provided with a chance to depart, by an intervention of the Supreme Court. But the medications he received were never made public. What was the protocol followed? How frequently was he monitored? What was recorded?

One risks never knowing.

Is there a need to develop institutional protocols defining medications to be used while instituting withdrawal of treatment in select circumstances?

I left the intensive care unit wondering what exact purpose had my consultation served. I had neither been able to alter the trajectory of treatment nor changed the family’s understanding. Yet perhaps that was not the real measure of my value. The patient remained too obtunded to have any semblance of consciousness. To my credit, his wife was not forced into a conversation she had repeatedly signalled she was unable to have. The treating team reached a shared understanding that survival was unlikely, while acknowledging that prognostication remained uncertain, though entirely bleak.

Sometimes, the most appropriate intervention is restraint. Whether this should be regarded as therapeutic humility or masterly inactivity remains open to debate. What is less debatable is the need for clinicians to develop protocols for the compassionate withdrawal of life-sustaining treatment.

Cite as – Arora, R. D. (2026). Reflections from the Bedside (RB8): Encountering a determined caregiver at the bedside or “When masterly inaction equals good palliation”. Zenodo. https://doi.org/10.5281/zenodo.21275951

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. This article identifies Harish Rana but only touches upon information available in the public domain. 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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