Changes

== Introduction ==

== Introduction ==

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[[Yasyashyavanimittiyam Indriyam Adhyaya]] refers to color changes in eyes. In the first four chapters of [[Indriya Sthana]], conditions related to ''Indriya'' or five sense organs have been described. In those chapters, derangement in functional aspects of ''indriyas'' have been given importance and Atreya told to examine them by the help of ''Anumana Pramana''. In this chapter certain anatomical changes or changes which can be examined by ''Pratyaksha Pramana''(direct observation) are mentioned which are equally important indicators of life span.  

[[Yasyashyavanimittiyam Indriyam Adhyaya]] refers to color changes in eyes. In the first four chapters of [[Indriya Sthana]], conditions related to [[Indriya]] or five sense organs have been described. In those chapters, derangement in functional aspects of [[indriya]] have been given importance and Atreya told to examine them by the help of logical inference ([[anumana pramana]]). In this chapter certain anatomical changes or changes which can be examined by direct observation([[Pratyaksha Pramana]]) are mentioned which are equally important indicators of life span.  

Nowadays, importance is given to the identification of approaching death. Educational and training programs are organized to educate family members/relatives/attendants so that patient care is not neglected near death and this specialized field is commonly known as Palliative care. The World Health Organization (WHO) defines palliative care as 'an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psycho-social and spiritual'.<ref> Available from: http://www.who.int/hiv/topics/palliative/PalliativeCare/en/ </ref>

Nowadays, importance is given to the identification of approaching death. Educational and training programs are organized to educate family members/relatives/attendants so that patient care is not neglected near death and this specialized field is commonly known as Palliative care. The World Health Organization (WHO) defines palliative care as 'an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psycho-social and spiritual'.<ref> Available from: http://www.who.int/hiv/topics/palliative/PalliativeCare/en/ </ref>

The aging of the population, with the numerous chronic debilitating and malignant conditions associated with growing older, has focused attention on palliative care. The terminal state is an integral process and a time to reconcile differences so that patient and family may accept death with a minimum of physical, spiritual, and psycho-social anguish.<ref> Rousseau P., Hospice and palliative care, Dis Mon. 1995 Dec;41(12):779-842. </ref> Hospice care is a specialized philosophy and system of care for the terminally ill patient that accepts death in an affirmative way and provides palliative care and emotional support to dying patients and their families.<ref> Plumb JD, Ogle KS., Hospice care, Prim Care. 1992 Dec;19(4):807-20. </ref> Hospice and palliative care philosophy lays emphasis on relieving suffering and improving quality of life at the end of life in order to permit experiences that will have positive meaning. The role of the physician is central in providing this care.<ref> Sethi S. Hospice: an underutilized resource, J Okla State Med Assoc. 2001 Mar;94(3):79-84. </ref> When recovery is uncertain it is better to discuss this rather than giving false hope to the patient and family. This is generally perceived as a strength in the doctor-patient relationship and helps to build trust.<ref> John Ellershaw, Care of the dying patient: the last hours or days of life, BMJ. 2003 January 4; 326(7379): 30–34. </ref> Charak also supports this view and states that those near death should not be treated. Thus it becomes important that physician should be well trained in identifying features of impending death.

The aging of the population, with the numerous chronic debilitating and malignant conditions associated with growing older, has focused attention on palliative care. The terminal state is an integral process and a time to reconcile differences so that patient and family may accept death with a minimum of physical, spiritual, and psycho-social anguish.<ref> Rousseau P., Hospice and palliative care, Dis Mon. 1995 Dec;41(12):779-842. </ref> Hospice care is a specialized philosophy and system of care for the terminally ill patient that accepts death in an affirmative way and provides palliative care and emotional support to dying patients and their families.<ref> Plumb JD, Ogle KS., Hospice care, Prim Care. 1992 Dec;19(4):807-20. </ref> Hospice and palliative care philosophy lays emphasis on relieving suffering and improving quality of life at the end of life in order to permit experiences that will have positive meaning. The role of the physician is central in providing this care.<ref> Sethi S. Hospice: an underutilized resource, J Okla State Med Assoc. 2001 Mar;94(3):79-84. </ref> When recovery is uncertain it is better to discuss this rather than giving false hope to the patient and family. This is generally perceived as a strength in the doctor-patient relationship and helps to build trust.<ref> John Ellershaw, Care of the dying patient: the last hours or days of life, BMJ. 2003 January 4; 326(7379): 30–34. </ref> Charak also supports this view and states that those near death should not be treated. Thus it becomes important that physician should be well trained in identifying features of impending death.

In order to care for dying patients it is essential to “identify dying”. This aim can be attained by applying the knowledge given in this chapter. Presently to predict prognostic value few tools have been designed. Most widely-used prognostic tools is the Palliative Performance Scale (PPS) which has been studied primarily in inpatient settings and in patients with cancer. Few researches are on going to develop tools for prognosis in other diseases also.<ref> Harrold J, Rickerson E, Carroll JT, McGrath J, Morales K, Kapo J, Casarett D., Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population?, J Palliat Med. 2005 Jun;8(3):503-9. </ref> Research can be done to develop a scale based on parameters described in Ayurvedic ''Arishta Vigyana'' and this chapter can also contribute a lot in making such kind of tool.

In order to care for dying patients it is essential to “identify dying”. This aim can be attained by applying the knowledge given in this chapter. Presently to predict prognostic value few tools have been designed. Most widely-used prognostic tools is the Palliative Performance Scale (PPS) which has been studied primarily in inpatient settings and in patients with cancer. Few researches are on going to develop tools for prognosis in other diseases also.<ref> Harrold J, Rickerson E, Carroll JT, McGrath J, Morales K, Kapo J, Casarett D., Is the palliative performance scale a useful predictor of mortality in a heterogeneous hospice population?, J Palliat Med. 2005 Jun;8(3):503-9. </ref> Research can be done to develop a scale based on parameters described in Ayurvedic [[Arishta]] [[Vigyana]] and this chapter can also contribute a lot in making such kind of tool.

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== Sanskrit text, Transliteration and English Translation ==

== Sanskrit text, Transliteration and English Translation ==

Note: The chapter deals with sensorial prognosis from the observation of the dark brown color of the eye of a man.  

Note: The chapter deals with sensorial prognosis from the observation of the dark brown color of the eye of a man.  

=== Signs of death due to ''Pitta'' disorders ===

=== Signs of death due to [[Pitta]] disorders ===

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The man whose veins are green and whose hair follicles are closed and who craves for sour things succumb to death due to ''pitta'' disorders. [3-5]

The man whose veins are green and whose hair follicles are closed and who craves for sour things succumb to death due to ''pitta'' disorders. [3-5]

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=== Signs of death due to ''Rajayakshma'' and ''Shosha'' ===

=== Signs of death due to [[Rajayakshma]] and [[Shosha]] ===

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In a patient of ''rajyayakshma'', waning strength, shining extremities and emaciated body parts denotes that patient will succumb to death soon.   

In a patient of [[rajayakshma]], waning strength, shining extremities and emaciated body parts denotes that patient will succumb to death soon.   

The burning pain in the shoulder region, hiccup, hematemesis, distension of the stomach and pain in the flanks in patient of consumption will end the life of patient. [6-7]

The burning pain in the shoulder region, hiccup, hematemesis, distension of the stomach and pain in the flanks in patient of consumption will end the life of patient. [6-7]

   

   

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When diseases like ''Vatavyadhi'' (diseases due to ''vata''), ''Apasmara'' (Epilepsy), ''Kushtha'' (Skin diseases), ''Shopha'' (Swellings), ''Udara'' (abdominal diseases including ascitis), ''Gulma'' (lumps and tumors), ''Madhumeha'' (urinary disorders including Diabetes) and ''Rajayakshama'' (Tuberculosis) are associated with loss of strength and muscle wasting then such patient should be discarded by the physician as patient will not recover and will succumb to death.

When diseases like [[Vatavyadhi]] (diseases due to [[vata]]), [[Apasmara]] (Epilepsy), [[Kushtha]] (Skin diseases), [[Shopha]] (Swellings), [[Udara]] (abdominal diseases including ascitis), [[Gulma]] (lumps and tumors), [[Madhumeha]] (urinary disorders including Diabetes) and [[Rajayakshama]] (Tuberculosis) are associated with loss of strength and muscle wasting then such patient should be discarded by the physician as patient will not recover and will succumb to death.

Patients suffering from other diseases too having above features should be avoided by the physician. [8-9]

Patients suffering from other diseases too having above features should be avoided by the physician. [8-9]

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=== Death signs after ''Virechana'' (purgation) ===

=== Death signs after [[Virechana]] ( therapeutic purgation) ===

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One who, because of excessive dryness of throat, mouth and chest, is unable to drink anything does not survive.

One who is unable to drink anything because of excessive dryness of throat, mouth and chest does not survive.[11]

=== Feeble voice as death sign ===

=== Feeble voice as death sign ===

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The man speaking irrelevantly about death or patient suffering from auditory hallucinations should not be treated.

The man speaking irrelevantly about death or patient suffering from auditory hallucinations should not be treated.

If in any disease, patient deteriorates all of a sudden, his survival is doubtful as told by Atreya. If the relatives of the patient request the physician begging for his life, the physician should prescribe the diet of soup prepared out of meat; but no ''Shodhana'' (purificatory therapy) should be done in such patient as it will further deteriorate the condition.

If in any disease, patient deteriorates all of a sudden, his survival is doubtful as told by Atreya. If the relatives of the patient request the physician begging for his life, the physician should prescribe the diet of soup prepared out of meat; but no [[Shodhana]] (purification therapy) should be done in such patient as it will further deteriorate the condition.

If after one month, no signs of improvement as the result of soup prepared out of meat and varied other nutritive agents are seen, then the patient’s survival is rare. [14-17]

If after one month, no signs of improvement as the result of soup prepared out of meat and varied other nutritive agents are seen, then the patient’s survival is rare. [14-17]

If the sputum has various color and sinks in water, the patient does not survive.

If the sputum has various color and sinks in water, the patient does not survive.

The morbid condition in which the ''pitta'', reaches up to temporal area and accumulates there, is known by the name of ''Shankhaka''. It kills the patient in three nights.  

The morbid condition in which the [[pitta]], reaches up to temporal area and accumulates there, is known by the name of [[Shankhaka]]. It kills the patient in three nights.  

The man frequently spitting frothy blood and suffering from piercing pains in the stomach, should be refused for the treatment by the physician.

The man frequently spitting frothy blood and suffering from piercing pains in the stomach, should be refused for the treatment by the physician.

It is not necessarily that one founds them collectively in one person who is approaching death. Only few of them may appear in one person.

It is not necessarily that one founds them collectively in one person who is approaching death. Only few of them may appear in one person.

Hence,the physician should know with all the signs and symptoms, prognosticative of death. [23-24]

Hence, the physician should know with all the signs and symptoms, prognosticative of death. [23-24]

== Tattva Vimarsha (Fundamental Principles) ==

== Tattva Vimarsha (Fundamental Principles) ==

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Various biomarkers have been developed since the time of Charak and many diseases which were incurable can be controlled. Patient should be evaluated using these biomarkers, before communicating to the patient and family about remaining lifespan of patient.

*Various biomarkers have been developed since the time of Charak and many diseases which were incurable can be controlled. Patient should be evaluated using these biomarkers, before communicating to the patient and family about remaining lifespan of patient.

The ''bala'' (strength and immunity) and ''mamsa'' (muscle mass) are important markers for assessment of health and death. Depletion of these two markers indicates near death signs. [8-9]

*The [[bala]] (strength and immunity) and [[mamsa]] (muscle mass) are important markers for assessment of health and death. Depletion of these two markers indicates near death signs. [8-9]

Change in eye color, voice, sputum, feces and semen are markers of near death.

*Change in eye color, voice, sputum, feces and semen are markers of near death.

== Vidhi Vimarsha (Applied Inferences ) ==

== Vidhi Vimarsha (Applied Inferences ) ==

General examination is important for assessing life span of any individual. Treatment should be planned after complete examination of disease and patient including the biomarkers.  

General examination is important for assessing life span of any individual. Treatment should be planned after complete examination of disease and patient including the biomarkers. Cravings for substances which increases vitiation of causative [[dosha]] reflects grave prognosis of the disease. [Verse 3-5]

Cravings for substances which increases vitiation of causative Dosha reflects grave prognosis of the disease. [Verse No. 3-5]

Patient with poor strength will die with consumption, as the patient will not be able to fight disease and will succumb to death. [Verse 6-7]

''Ashta Mahagada'' , or eight grave diseases, are difficult to treat. They should not be treated if they are associated with loss of strength with muscle wasting.[8-9]  

Eight grave diseases ([[Ashta Mahagada]]) are difficult to treat. They are incurable if associated with loss of strength with muscle wasting.[Verse 8-9]

 

 

If patient suffers from an incurable disease and shows [[arishta]] signs, physician should inform the relatives about the exact condition of the patient and suggest care to keep the patient comfortable. If the legal guardian of the patient requests the physician for treatment then only he should treat the patient. [Verse 14-17]

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