Jayalalithaa's medical treatment

Record of a lost battle

Print edition : March 01, 2019

Jayalalithaa. Photo: A. SHAIKMOHIDEEN

The crowd outside Apollo Hospitals in Chennai on December 5, 2016. Photo: Bijoy Ghosh

V.K. Sasikala. Photo: K.V. Srinivasan

O. Panneerselvam. Photo: PTI

Dr Prathap Reddy, chairman, Apollo Hospitals, Chennai. Photo: V. Ganesan

C. Vijayabaskar, State Health Minister. Photo: B. JOTHI RAMALINGAM

With conspiracy theories doing the rounds over Tamil Nadu Chief Minister Jayalalithaa’s death, often floated by Ministers and members of the ruling AIADMK itself, Frontline looks in detail at the reports of Apollo Hospitals, Chennai, and AIIMS, New Delhi, to piece together what happened in the days preceding her death.

TAMIL NADU Chief Minister Jayalalithaa’s death after 74 days in hospital is now the subject of a commission of inquiry headed by Justice A. Arumughaswamy, a retired judge of the Madras High Court, after questions about the medical treatment given to her were raised within her own party, the All India Anna Dravida Munnetra Kazhagam (AIADMK), and by her political opponents, mainly the Dravida Munnetra Kazhagam (DMK). In fact, the DMK, which is the principal opposition party in the State, demanded a probe by the Central Bureau of Investigation. The commission, formed in September 2017, is inquiring into the circumstances leading to her death on December 5, 2016, and has been given multiple extensions already.

The probe itself came about because of the factionalism within the AIADMK. The then Chief Minister, O. Panneerselvam, who led a faction within the AIADMK then, staged a “dharma yudh” against Jayalalithaa’s close aide V.K. Sasikala and insisted on a probe when conspiracy theories about the former Chief Minister’s death started doing the rounds. The matter continued to simmer even as factional politics within the ruling AIADMK took centre stage and resulted in Edappadi K. Palaniswami becoming Chief Minister in February 2017.

With Panneerselvam showing no sign of withdrawing his demand for a probe, the Chief Minister, in August 2017, announced the setting up of the inquiry commission and a few days later inducted Panneerselvam into his Cabinet as Deputy Chief Minister. Clearly, Palaniswami’s aim, while assuaging the frayed tempers of Panneerselvam, was to alienate Sasikala and her nephew T.T.V. Dinakaran and foil their attempts to take control of the party.

However, Palaniswami’s strategy did not silence AIADMK functionaries, even Ministers, who continued to make conflicting and controversial statements on the death of their leader. This had the effect, perhaps unintended, of embarrassing the government officials who had monitored her treatment. Forest Minister Dindigul C. Srinivasan, while addressing a public meeting in Madurai last year, said leaders had “lied to the people that the leader [Jayalalithaa] ate idlis”. He said that none of the functionaries, barring a few, were allowed to see the ailing Chief Minister though the medical reports of Apollo Hospitals, where she was treated, claimed that periodical briefings about her condition were held with senior Cabinet Ministers and officers.

Recently, Law Minister C.Ve. Shanmugam revived the issue that was thought to have been settled to everyone’s satisfaction. Jayalalithaa, he said, should have been taken abroad for treatment. He launched a broadside against Health Secretary J. Radhakrishnan’s statement that “Indian doctors are good” and for “misguiding the Cabinet”. He also asked why an angiogram was not performed on her soon after she was brought to the hospital. Fisheries Minister D. Jayakumar went a step further and said those who were found to be at fault while deciding the line of treatment for their leader should be dealt with as per “police enquiry techniques”.

“These statements on Jayalalithaa’s death and other political developments point to only one thing: an attempt to fix the blame on someone for Jayalalithaa’s medical treatment,” said a senior official. “It is unfortunate that the best professional medicare that was given to her has been questioned,” said a physician who treated her. Apollo Hospitals asked the commission of inquiry to form a medical board to evaluate the treatment history of the Chief Minister. “We have submitted nearly 10,000 medical documents relating to her treatment. The commission must form a medical board to understand treatment and terminologies,” said the physician. Apollo Hospitals has told the commission that its medical experts would not be available for re-examination at present.

The commission, which has the powers of a civil court, is conducting the proceedings in camera. Sasikala’s counsel, Raja Senthoor Pandian, told the media that the panel was yet to question Panneerselvam and DMK president M.K. Stalin, “two key witnesses who could untie the knots that have been built around Jayalalithaa’s death”. On February 5, the commission adjourned further hearing to February 11.

A press release from the Health Secretary, issued on March 6, 2017, while placing the medical reports—including the discharge summary from Apollo Hospitals and the medical reports from the All India Institute of Medical Sciences (AIIMS), New Delhi—concerning her treatment in the public domain, claimed that though it was unethical to reveal the details of a patient’s treatment under the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, the Government of Tamil Nadu had to resort to this act “to put at rest needless speculation relating to the circumstances surrounding the hospitalisation, treatment and sad demise of the late Honourable Chief Minister of Tamil Nadu”.

In October 2018, the Raj Bhavan wrote to the Justice A. Arumughaswamy Commission saying that it had received no medical records from Apollo Hospitals or AIIMS pertaining to the health of Jayalalithaa, a report in The Economic Times said. The government letter was in the context of a communication from the commission seeking information about official communique between institutions such as the Raj Bhavan, the government, the hospital group and AIIMS, the report said. A search of the Tamil Nadu government’s Information and Public Relations website and other government websites could not locate the medical records.

Conspiracy theories

One of the conspiracy theories was about the medical treatment, or the lack of it, given to her at her Poes Garden residence until Jayalalithaa was rushed to hospital, something which Panneerselvam had demanded from the beginning (see “They started ill-treating me”, Frontline, March 3, 2017). A detailed medical history of Jayalalithaa in the period before her hospitalisation could not be accessed, though one did get glimpses of it in the medical reports of Apollo Hospitals and AIIMS, New Delhi, whose doctors visited the ailing Chief Minister five times on the directions of the Government of India. Copies of both medical reports are with Frontline.

Apollo Hospitals recorded that during her admission on September 22, Jayalalithaa was suffering from “multiple medical problems”. She had been an acute diabetic for 20 years and was suffering from hypertension. The reports claimed that she had a history of chronic seasonal bronchitis and hypothyroidism, besides irritable bowel syndrome with chronic diarrhoea. She was also suffering from atopic dermatitis and was on a tapering dose of oral steroids for this. An echo test had been done a year earlier, the report noted. It should be noted here that the physician who was treating her regularly at her home happened to be a relative of Sasikala.

In fact, even on the day of her admission to Apollo Hospitals, she, according to press releases of the State government, executed her official duties. She condoled the death of the Carnatic singer M. Balamuralikrishna, who died on September 22, in a press release. On September 21, she inaugurated the Adani Group’s mega solar energy project. She also inaugurated various projects and distributed freebies to beneficiaries of welfare schemes.

On September 23, she reportedly responded to messages from Prime Minister Narendra Modi and the then Tamil Nadu Governor, Ch. Vidyasagar Rao, wishing her a speedy recovery. The Governor visited her later in the hospital.

On September 27, she held a high-level discussion with top officials on the Cauvery issue “in her room in Apollo Hospitals”. A month later, on October 27, at 6:30 p.m., she affixed her thumb impression on documents relating to the allotment of the party symbol to candidates contesting the Assembly byelection in 2017. A government doctor, P. Balaji, attested it.

These acts supported the claim of the doctors who treated her that she had been intermittently conscious. “The ebb and flow of her condition, though not abnormal in medical history, complicated her clinical progress,” said a top Health Department official. He dismissed allegations of a “veil of secrecy” surrounding her treatment and said: “Medical practices do not permit a conjecture of ifs and buts and whys and why nots in the line of treatment. It is a well-laid-out norm.”

The Apollo Hospitals’ report said that a panel of experts was formed and multidisciplinary discussions were held regularly for a consensus on the line of treatment. Also, a panel of physicians updated the patient’s family and a core group of government officials, and a government-designated medical team examined her periodically throughout her stay in the hospital, and all of them “concurred with the treatment plan” (according to the hospital records, “family” in this context meant “Sasikala”).

A spokesperson of the hospital said there was no ambiguity whatsoever in her treatment as claimed by some. On September 23, the hospital issued a press release saying merely that the Chief Minister had been admitted with “fever and dehydration”. On September 25, it held a press conference to say that she was “recovering well”. Dr Richard Beale, Professor of Intensive Care and Medicine, and Consultant, Guy’s Hospital and St. Thomas Hospital, United Kingdom, who treated her, said in a recent video that the Chief Minister herself was not inclined to go abroad for treatment.

On September 29 and on October 2, the hospital issued press notes saying that she would have to be in the hospital for a few more days. The hospital also posted her health updates on Twitter. Despite all these steps, rumours and statements about her health had begun to be circulated widely.

Her medical reports indicated that even while she was showing improvement, she collapsed. Almost all the top cardiologists in Chennai were involved in her treatment, but most of them chose not to share their views owing to the politics around her death. Frontline spoke to a medical expert in the United States about the Apollo Hospitals and AIIMS reports. After a careful review of the reports, he said: “The treatment has been outstanding, about as good as you could expect in any advanced medical centre.” On the claims made that an angiogram or angioplasty soon after she was admitted in the hospital could have saved her, he said, on the basis of the report: “There was never any indication by history, exam or testing of coronary ischemia which would have demanded an angiogram or angioplasty. Thus an angiogram was not indicated in the first place.”

Apollo Hospitals’ report

The 12-page treatment summary of the Department of Critical Care Medicine of Apollo Hospitals, Chennai, was written in consensus with “all treating physicians”. Among those who advised and reviewed the treatment of the former Chief Minister were 17 specialists from various departments of Apollo Hospitals, six specialists from AIIMS, New Delhi, and 12 “external experts” from the U.S., the U.K., Mumbai, Hyderabad, Bengaluru, Vellore and Chennai, including Dr Beale and Dr Stuart Russell, a cardiologist from Johns Hopkins Hospital in the U.S.

The summary claimed that Jayalalithaa was diagnosed to be suffering from multiple issues such as enterococcus bacteremia with septic shock and ARDS (acute respiratory distress syndrome) with secondary pulmonary infections requiring prolonged ventilator support; infective endocarditis of calcified mitral valve with valve perforation, mitral regurgitation (MR) and first degree AV (atrioventricular) block; heart failure with preserved systolic function; uncontrolled type-II diabetes mellitus; hypertension; hypothyroidism; asthmatic bronchitis and probable sleep apnoea; H/O irritable bowel syndrome; and atopic dermatitis.

Details of treatment

The Apollo Hospitals’ report claimed that on September 22, 2016, their ambulance services were called to the Chief Minister’s residence at about 10 p.m. On reaching her house, the team noted that “she was not consistently responding to calls and was also breathless with low oxygen saturations (approximately 48 per cent). Initial pulse rate [was] 88/min and B.P. 140/70. She was given oxygen supplementation through a face mask with which oxygen saturation improved to 98 per cent, and then was immediately shifted to Apollo Hospital Emergency Room (E.R.).” On arrival, she was “noted to have altered sensorium” and was in respiratory distress. A systemic examination revealed “bilateral basal crackles in the lungs, soft heart sounds and clinically normal abdominal examination”.

Medical procedures, such as electrocardiogram (ECG) and echo (echocardiogram) were done. The ECG report indicated “suggestive [of] sinus tachycardia (faster-than-usual heart rhythm) with prolonged PR interval”. A 2D echocardiogram “revealed normal LV [left ventricle] and RV [right ventricle] functions with no evidence of pericardial effusion”. Lung ultra sonogram (USG) revealed “extensive bilateral B profile indicative of pulmonary oedema [fluid accumulation in the lungs]”. The report said that Jayalalithaa “was admitted in a very critical condition”.

In the initial few hours in the hospital, she was treated for pericardia arrest situation “as per ACLS protocol [Advanced Cardiovascular Life Support, which refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening cardiovascular emergencies] with injection of Atropine and subsequently a temporary transvenous pacemaker was emergently inserted by cardiologist”. She was treated for symptomatic bradycardia (slow heart rate, generally fewer than 60 beats a minute) too.

At that time “serial ECGs and cardiac enzymes were not suggestive of an acute coronary event”. The report further said that it reviewed her “prior medications”, including beta blockers and other anti-hypertensives. She showed improvement. “Although her dyspnea [laboured breathing] did not change significantly on the second day, her tachypnea [abnormally rapid breathing] and oxygen requirement improved and her sensorium also returned to baseline. She interacted with family members and government officials,” the report said.

The report was cautious while profiling her past medical history, which has become a subject of debate today. It claimed that her medical history was significant since her multiple medical problems included obesity, hypertension, poorly controlled diabetes, hypothyroidism, irritable bowel syndrome with chronic diarrhoea and seasonal bronchitis. “She was also on a tapering dose of oral steroids for atopic dermatitis. She had a history of intermittent fever for 5-7 days with increased frequency of bowel movement,” the report stated.

Repeated transthoracic echocardiograms were performed at the hospital to evaluate for possible infective endocarditis. A transoesophageal echocardiogram was not possible initially because of the patient’s tenuous respiratory distress syndrome. But her clinical course deteriorated on the fourth day of her stay when she started to develop a “significant audible wheeze” and increasing tachypnea. “Repeated TTE [transthoracic echocardiogram] was suggestive of slightly increasing MR and left arterial dimensions, but no valve abscesses, conduction delays or other sequelae of infective endocarditis [an infection of the endocardium, the inner lining of the heart chambers and valves] needing surgical intervention. Cardiothoracic surgical input was obtained and no acute surgical intervention was deemed necessary,” the Apollo Hospitals’ report stated.

Jayalalithaa slowly responded to treatment, and on September 27 she “was able to interact with government officials from the bedside”. In fact, a press release from the Director of Information and Public Relations issued on September 27, 2016, stated that the “Honourable Chief Minister, Selvi J Jayalalithaa convened a meeting between 4:30 p.m. and 5:30 today (27-9-2016) in her room in the Apollo Hospital, Greams Road, Chennai, on the interim directions issued by the Supreme Court on the Cauvery issue.” The Chief Minister, the release added, was apprised of the directions of the Supreme Court. Chief Secretary P. Rama Mohana Rao, Advocate General R. Muthukumaraswamy, Adviser Sheela Balakrishnan, Principal Secretary-1 to Chief Minister K.N. Venkataramanan and Secretary-IV A. Ramalingam participated in this meeting.

The Chief Minister, the release said, directed Minister for Public Works, Highways and Minor Ports Development Edappadi K. Palaniswami; Chief Secretary Rama Mohana Rao; Principal Secretary in the Public Works Department, S.K. Prabakar; and Chairman of the Cauvery Technical Cell R. Subramanian to attend the meeting on the Cauvery issue to be held in New Delhi on September 29.

Last official meeting

That was the last time she attended an official interactive discussion on an important issue in her capacity as Chief Minister. Although the State government issued press releases in her name after she was admitted to Apollo Hospitals, there are no records to suggest any more active participation in or discharge of official duties by her as Chief Minister thereafter until her death on December 5. The only other thing she did was to affix her thumb impression in October on the application for the party’s candidate contesting the byelection at Thirupparankumdram in 2017.

On September 28, the day after the official meeting on the Cauvery issue, Jayalalithaa developed an acute bout of wheezing and breathlessness with worsening hypoxaemia (low oxygen level in arterial blood) and “after obtaining informed consent from the family and core government officials, patient was successfully intubated” (placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) and after that a TOE (transoesophageal echocardiogram, an ultrasound of the heart that scans the heart from inside the oesophagus) was performed to stabilise hemodynamics.

The report mentions that the TOE showed no evidence of mitral valve annular abscess or AV ring abscess, suggestive of non-hemodynamically significant MR. The left main coronary artery, ostio-proximal LAD (left anterior descending artery) and left circumflex (curved) and ostio-proxmal RCA (right coronary artery) were clear and of normal calibre.

However, the report added that a panel of cardiologists and cardiothoracic surgeons, including Dr M.R. Girinath, Dr K.M. Cherian and Dr L.F. Sridhar, reviewed the patient and the TOE findings and “recommended continuation of medical therapy as there was no indication of emergency surgery”. Further clinical examination, however, suggested that she was suffering from pulmonary oedema, which later emerged as one of the major causes for her death.

Dr Pranatharthi H. Chandrasekhar, Professor, Infectious Diseases Department, Wayne State University, Detroit, U.S., was consulted over phone and on his advice, appropriate modifications were carried out. A panel of intensivists, including Dr Jigi Divatia from Mumbai, and infectious diseases specialists, including Dr O.C. Abraham from CMC Vellore and Dr Rajeev Soman from Mumbai, evaluated the case independently and provided inputs. Later, antibiotics were de-escalated. Her condition stabilised.

But on September 30, there was a worsening of respiratory dynamics, which required “escalation of sedation, oxygen supplementation”. Tests revealed worsening of pulmonary oedema. Dr Beale was invited to provide an expert opinion. After extensive discussion and evaluation, he suggested Levosimendan infusion to address the diastolic dysfunction. “He also counselled the family and the government officials about the nature of problems, the need for prolonged ICU and hospital stay and guarded prognosis.” The report said: “He was of the opinion that considering her overall condition she carries a mortality of 40 per cent.”

The following two days went without any significant change in her overall condition. D. Ravi Mehta, Senior Consultant, Pulmonary and Critical Care Medicine, Apollo Hospitals, Bengaluru, was consulted. On October 2, the long-time I.V. access and all central catheters were removed. Subsequently, an experts’ team from AIIMS, New Delhi, held a detailed discussion with the treating team and “concurred with the plan of management and updated the family members and senior government officials. The team from AIIMS and Dr Richard Beale subsequently visited the patient several times in the ICU and provided inputs on care.”

The AIIMS team was formed as per an order of October 5, 2016, by its Director on directions from Union Health Minister Jagat Prakash Nadda. A team of specialists—Dr G.C. Khilnani, Professor, Department of Pulmonary Medicine and Sleep Disorders; Dr Anjan Trikha, Professor, Department of Anesthesia, Critical Care and Pain Medicine; and Dr Nitish Naik, Professor, Department of Cardiology—visited Chennai from October 5 to October 7, 2016. “The team had a meeting with all the specialists who are looking after the Honourable Chief Minister. They included Critical Care Specialist (Intensivist), Pulmonologist, Cardiologist, Infectious Disease Specialist, Endocrinologist, Gynaecologist and others,” said AIIMS in its report. It filed five reports on the medical condition of the Chief Minister to the Government of India.

Its first report said her transthoracic echocardiogram, done by the treating team, revealed “mitral annular calcification and mild mitral regurgitation. The other valves were normal. The left ventricular systolic function was normal along with evidence of diastolic dysfunction.” On the day of the team’s first visit, she was on ventilator support with invasive monitoring. “Our team examined her and suggested tracheostomy for further management and reducing the sedation. It was also opined that the procedure should be performed by an ENT surgeon in operation theatre.”

‘Surgery not preferred’

The option of surgical intervention for MR (mitral regurgitation) was discussed. Prof. Naik opined that “immediate surgery at this point of time was not preferred because of very high operative risk”. However, he asked for a close watch to monitor any increase in the severity of MR, development of new lesions or any other possible indication for surgery for infective endocarditis. The team examined her the next day too. Her clinical condition remained the same, which was conveyed to the Chief Secretary of Tamil Nadu and the Chairman of Apollo Hospitals, Dr Prathap C. Reddy. The report claimed that a tracheostomy was performed on her at 4:30 a.m. on October 7, which was uneventful. She was stable and responded to verbal commands. The AIIMS team observed that she continued to be critically ill.

The report from Apollo Hospitals said that “considering the recurring pulmonary oedema, underlying co-morbidities, [the] likely need for long term ventilator support and ease of further care, [a] consensus decision was made to perform an electric tracheostomy. Family and senior government officials were counselled and consent obtained and tracheostomy performed on October 7, 2016, by Dr Babu Manohar (ENT) in the operating room uneventfully.” She, as per the records, however, continued to suffer from periods of hypertension, tachycardia, pulmonary oedema, etc., thereafter, and the reaccumulation of pleural effusion on both sides of her lungs was noticed on October 9.

Dr Khilnani from AIIMS returned on October 9 to assess the situation. He took a briefing from Dr Babu Abraham, the treating physician, and examined the Chief Minister. There was a change in her respiratory parameters since the pleural effusion in the lungs. The therapy was intensified. She continued to be on full ventilator support and other medications. Dr Khilnani briefed Health Minister C. Vijayabaskar and Health Secretary J. Radhakrishnan about the Chief Minister’s medical condition.

On October 14, a CT scan of the chest/abdomen/pelvis was done. The Apollo Hospitals’ report added: “Patient’s family requested us to obtain the expert opinion of an external cardiologist during the hospital stay.” At various points, Dr Russell and Dr Jayan Parameshwar, Medical Head of Heart Failure and Heart Transplantation, Papworth Hospital, U.K., were consulted over phone and through telemedicine and inputs obtained. Both of them attributed the recurrent episodes of breathlessness and transudative pleural effusion to a combination of diastolic heart failure and capillary leak syndrome and they advised continued diuresis.

Dr Mathew Samuel, senior interventional cardiologist, “evaluated the patient’s clinical condition and concurred with optimisation of medical management and opined that there was no need for an urgent coronary angiogram or intervention”. Hence, the optimisation of cardiac medicines and other medicines on an as-and-when-required basis were administered. Repeated transthoracic echocardiograms “did not show any new worsening of mitral valve vegetation, wall motion abnormalities or drop in EF [ejection fraction].” The report claimed that the patient “continued to interact and was able to communicate her needs to the nursing and the medical team”.

The condition of the Chief Minister improved gradually over the next five days after the October 9 setback, and she was put on oral feeds. Her overall medical management plan was redrafted, though all medication for cardiac optimisation with a sustained back and perennial care was maintained. Her nasogastric tube was removed and “[she] did not want it reinserted”. Oral nutrition support was added, and the patient was encouraged to take as much protein and calorie-rich food as possible in her oral intake.

The AIIMS team returned to Chennai and evaluated her health from October 13 to October 15. The team studied the reports and had a meeting with specialists on October 14 to decide the future course of action. “This was held in the office of Dr Prathap C. Reddy, Chairman of Apollo Group of Hospitals. After detailed discussions, it was decided not to do any active intervention for pleural effusion and continue same treatment with negative fluid balance and life support,” the AIIMS report said.

The same evening, a videoconference was arranged with Dr Russell in the U.S., in which all treating physicians took part. All the aspects of the medical reports and treatments were discussed. Dr Russell completely agreed with the line of treatment. On October 15, there was a briefing for senior Ministers and government officials, including the Chief Secretary, in the office of Dr Prathap Reddy.

All the details about the progress in the medical condition of the Chief Minister were communicated and discussed in detail. The AIIMS team emphasised and conveyed to the group that complete recovery was going to take a few weeks. The senior Ministers, including the Minister of Health, and senior officers appreciated AIIMS for sending the team three times at short notice. “They also appreciated the medical advice of the team.” The doctors returned to New Delhi after reviewing the clinical progress on the evening of October 15.

The first three weeks of November passed without any major incident for the patient. Even antibiotics were suspended and physiotherapists from Singapore were invited to provide both passive and active schedules of exercises. She even sat on the edge of the bed and on a wheelchair. On November 14, her tracheostomy tube was downsized to facilitate speech. On November 19, in view of her overall improvement, the patient was moved in a wheelchair out of the ICU to a specially designed high-dependency bed, with round-the-clock nursing and medical supervision.

Experts consulted

Dr Venkata S. Ram, a hypertension expert in Apollo Hospitals, Hyderabad, was consulted over phone on the episodic hypertension. He suggested screening for neuroendocrine tumour once the patient’s critical issues were improved. Dr Nikhil Tandon, Professor and Head, Department of Endocrinology, AIIMS, while examining the records and the patient, ruled it out as “highly unlikely”, and it was decided “not deemed immediately necessary” after conveying it to the family and government officers.

Dr Samin K. Sharma, Interventional Cardiologist in New York, was invited by the family for an expert opinion, and he provided inputs. The Apollo Hospitals’ report reiterated that during “the hospital stay including at presentation as well as during episodes of worsening breathlessness there was no symptomatic electrocardiographic (ECG monitor, 12 lead ECG) or echocardiographic (no regional wall motion abnormalities, no increase in LV diastolic dysfunction, no new LV systolic dysfunction, no increasing MR) evidence of ischemia”. On November 25, the tracheostomy tube was further downsized. After four days, on November 29, Holter monitoring was done, and it “revealed frequent ventricular premature contractions, but no evidence of significant arrhythmia or ST-T changes suggestive of ischemia”.

The AIIMS team visited Chennai again on December 3 with Dr Tandon accompanying it. The team was informed that the Chief Minister was progressing well and was undergoing physiotherapy regularly. On December 3, she reportedly suffered from decreasing potassium levels. She was found to be suffering from sensorimotor autonomic polyneuropathy. But she was fully conscious. She could sit in a chair for 20 minutes or so but could not stand as there was neuromuscular weakness. The team opined that the cause of episodic hypertension (fluctuations in blood pressure) was unlikely to be owing to an endocrine pathology and that “no invasive cardiologic investigation or intervention was indicated in the present condition”.

The AIIMS team interacted with the patient and encouraged her to increase her oral intake and participate more actively during the physiotherapy sessions. “They also agreed that coronary angiogram was not needed emergently and opined that it could be planned at a later date and conveyed this to the family and government officials,” the Apollo Hospitals report said. It added that a consensus decision was taken that further coronary evaluation could be planned electively at a later date. The team returned to Delhi the same day.

A decrease in the patient’s potassium level was recorded on December 4 too. Jayalalithaa’s condition suffered a further setback that day when she vomited after breakfast. She was placed back on the tracheostomy mask as her oxygen requirement increased. The Apollo Hospitals’ report said that at about 4:20 p.m. on December 4, while watching TV in the presence of nurses, the duty doctor and family members in the room, “she complained of worsening breathlessness and suffered from extensive wheezing. She was placed on ventilator to give maximum support to counter respiratory distress. At that time she had an episode of self-limited non-sustained ventricular tachycardia. But her condition degenerated to ventricular fibrillation.”

Hence, cardiopulmonary resuscitation (CPR) was started as per the ACLS protocol and defibrillation was done. She went into asystole (a most serious form of cardiac arrest, usually irreversible, and the state of total cessation of electrical activity from the heart) and then to PEA, or pulseless electrical activity, after the third cycle of CPR. An echo test revealed that there was no pericardial effusion, marginally dilated RV and no appreciable intra-cardiac valve leakage.

The report further added that the return of spontaneous circulation could not be obtained despite 30 minutes of CPR, and hence ECMO (extracorporeal membrane oxygenation) was initiated at around 5:30 p.m. The report detailed the prevailing condition of the patient and the treatment procedures. “At 10:30 p.m., the patient suffered purposeless blinking and pupils were sluggishly reacting. She slowly had intrinsic electrical activity but no significant ventricular ejection. At around midnight she was taken to the operating room for achieving adequate hemostasis by packing. Her chest was closed in layers and following which she was transferred to ICU.”

The AIIMS team, with Dr V. Devagourou, Professor, Department of Cardiothoracic and Vascular Surgery, joining it, rushed to Chennai and visited the Chief Minister on December 5. The team was informed that the Chief Minister had had a cardiac arrest at about 4:30 p.m. on December 4 and had also received cardiopulmonary resuscitation for 45 minutes, following which an open cardiac massage was done and she was put on ECMO and external cardiac pacemaker. She was put on hypothermia and was on continuous hemodialysis. The neurologist opined that there was no response to any stimuli. A neurological examination revealed brainstem dysfunction.

Last moments

A “desperate salvage therapy” was initiated. Family and core government officials were informed periodically about plans and progress. But Jayalalithaa never recovered a sustained intrinsic heart rhythm on effective ventricular ejection and was entirely dependent on VA-ECMO. At 10 p.m. again another round of clinical examinations, evaluations and ECMO was performed by the teams of doctors from Apollo Hospitals and AIIMS. “No intrinsic heart rhythm of viable ventricular ejection noted,” was their observation. The AIIMS team did an assessment on the patient soon after this. But all parameters denoted the futility of life support. Subsequently, a meeting was held under the chairmanship of Dr Prathap Reddy before the AIIMS team returned to Delhi on the morning of December 6.

The AIIMS report said: “The case was discussed in detail and our team agreed with the inference regarding futility of life support in view of clinical parameters. It was decided that the treating team would discuss the present clinical situation regarding futility of life support with the family members, relatives of Chief Minister and take further decision.” After a detailed discussion a consensus decision was arrived at that “continuing VA-ECMO and other organ supportive measures further was futile considering no intrinsic cardiac electrical and mechanical activity”.

The Apollo Hospitals’ report said that the condition of the Chief Minister “was conveyed to the government officials headed by the Chief Secretary (Rama Mohana Rao) and the Ministers headed by the senior Cabinet Minister (Hon Mr. O. Paneerselvam), Lok Sabha Deputy Speaker (Mr Thambidurai), Health Minister (Dr Vijayabaskar), Health Secretary (Dr J. Radhakrishnan) and family (Ms. Sasikala). All of them understood the situation and consented for withdrawal of ECMO.” After the ECMO withdrawal, the patient was declared dead at 11:30 p.m. on December 5. The causes of death, according to the hospital report, were ventricular fibrillation (disorganised electrical activity in the ventricles, a type of cardiac arrhythmia), infective endocarditis and acute respiratory distress syndrome. The report was signed by Primary Consultant, for Critical Care Consultants Group, Department of Critical Care Medicine, Apollo Hospitals, Chennai. No name was mentioned.

To dispel misgivings among the people, a press briefing was also organised on February 6, 2017, supported by the Tamil Nadu government, in which Dr Beale participated. Dr Beale, according to a report in The Economic Times, said diabetes had made her infection severe. He said that she could understand when spoken to, though she could not talk. Besides, people whom she wished to see and interact with were alone allowed to see her. He said that Sasikala and the Chief Secretary were briefed daily. Since there were issues with airlifting a critically ill patient, the idea of transferring her to a London hospital was dropped. Besides, when she was conscious, she did not want to be shifted, he said.

Dr Richard Beale further said: “It was a sudden witnessed cardiac arrest and there is nothing unusual about this case from a medical point of view. The only thing extraordinary was that the patient herself was extraordinary.”

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