Interview with Dr. Armando Caballero, chief of the Intensive Care Unit at the Arnaldo Milián University Hospital in Santa Clara, on the health condition of patient Guillermo Fariñas
By Deisy Francis Mexidor
Science, humanism, professionalism and the most advanced and costliest treatments have been used to save the life of patient Guillermo Fariñas. Science because sophisticated treatments have been applied in his case; humanism and professionalism because giving back health to human beings is the top aspiration of the prestigious specialists who are caring for him; and the most advanced and costliest treatments because the Cuban government has spared no effort to ensure this person the latest generation medications, the same used in other well-known healthcare centers, many of which must be bought from other countries.
On March 11, Fariñas was admitted to the Intensive Care Unit of the Arnaldo Milian University Hospital in the city of Santa Clara. The voluntary fasting he started more than 120 days ago has now become a threat to his life.
To inquire about his health, we traveled to the healthcare center in the central Cuban province and interviewed Dr. Armando Caballero, chief of the Intensive Care Services in the hospital.
First, we wanted to hear from this experienced Second Degree Specialist and founder of that special unit, how is it possible for a person to survive four months of fasting.
“Everybody is asking that,” he said, “because a person can’t live that long without nourishment; but that is not the case of Fariñas.”
Dr. Caballero explains that “this patient refuses to take food orally. He has been in this situation for 125 days, since he says he had spent two weeks in his house without eating before he was admitted to our services, where he has spent 110 days. On admission to the hospital, he showed some physical deterioration. He was conscious and he agreed that we provide him parenteral nourishment, that is, intravenously.
The patient is receiving amino acids that make up the proteins required by the body. He is also provided lipids, vitamins and minerals, “everything necessary in a balanced diet for any human being,” the doctor says. Then he adds that “Fariñas’ weight was 63 kg when he was admitted to our services, and at this moment it moves between 67 and 69 kilograms. He has recovered body weight during his hospital stay and this is due precisely to the parenteral nourishment he is receiving.”
How compromised is the patient’s health at this moment?
Parenteral nourishment requires that certain (osmolar) nutrients of high molecular weight pass through the central ducts of the human body. I mean, you need to catheterize major veins of the upper part of the body such as the subclavians and the internal jugulars, which can be hazardous and lead to complications, particularly when hyperosmolar nutrients, like amino acids and hypertonic dextrose, must pass through these catheters.
The risk of blood infections increases as time passes and the patients continue receiving this kind of nourishment. The tendency is for contamination and infection with bacteria and fungi or they develop other complications like we see in this patient now.
But, are these complications related to medical procedures or the care provided to this patient?
Absolutely not. These complications are a common occurrence in patients receiving this kind of nourishment. For example, in the 110 days that Fariñas has been our patient, we have had to change the catheter ten times. During his 251 days of fasting in 2006 –when he was also treated in our unit— he required 37 catheters. In my 37 years of experience in intensive care services, I never had another patient who required this procedure so many times.
In this case, four timely-detected infections were successfully treated with the corresponding medications for the type of staphylococcus that develops in the blood. In very instance, the germ was immediately isolated and efficiently combated with antibiotics and other specific measures.
But, from last week, the patient has developed another complication, which is not only an infection but something more serious. This time it’s thrombus phlebitis of the jugular-subclavian component in the neck veins. This thrombus or clot is very dangerous because it could detach and move toward the heart and from there to the lungs giving rise to a deadly pulmonary thromboembolism.
Such health condition is a relatively common occurrence in the hospitals and one of the causes of sudden death, when the thrombi are large. But sometimes they do not detach and can be dissolved with antibiotics and anti-clotting medications like we are applying to this patient. This time again, we have isolated the germ that caused the phlebitis of the central veins, which in this case is associated to the presence of the venous thrombus in the jugular-subclavian segment.
From last Sunday until today we have seen a slight improvement although we can’t say for sure that a more serious complication has been averted. No one can say here or anywhere in the world whether or not that thrombus will detach.
We have all the necessary medications. Last Saturday, when the complication was detected and the pathology confirmed with cutting-edge technology, we discuss collectively the diagnosis and treatment.
Is this the limit of what medicine can do in trying to save the life of this patient?
This is an extreme situation, mostly at this point. Since our patient-doctor relations are very good, we have discussed with him at length about abandoning his voluntary fasting and starting to take food orally in order to recover the energy he needs to fight the temperature caused by the infection.
It’s almost impossible to feed him through another catheter because new complications could arise when one is already developing. In his case, taking food is a crucial element in his fight for life.
What could happen if Fariñas insists on this behavior?
We feel that his condition could worsen, particularly the nutritional aspect, although until now we have been able to keep him stable despite his refusal to take nourishment orally.
And, what if he decided to eat?
The patient is perfectly prepared to take food orally. There is no contraindication in this regard. Simply his wish could be a major medical factor in the solution of his health condition.
What is the established medical procedure to deal with a patient who has decided not to ingest food?
As I said before, in my 37 years of experience in intensive care I have seen almost 20,000 patients, but Fariñas is the only one I’ve had here twice for voluntarily refusing to take food orally for a long period of time. This is not common. I’ve seen many patients in this unit; I’ve even treated persons who had tried to commit suicide for a certain reason, but at the end most want to live. That is what the doctors in this ward are asking Fariñas: that he helps us to save his life.
As to your question, there are no rules, but there is medical ethics. And, one of its basic principles is autonomy, that is, not to apply any procedure without the patient’s consent. We abide by that principle.
Fariñas is a patient who is conscious of his situation. He is not disoriented, he is in full command of his mental faculties, therefore, it is his right to accept or not, of his own volition, the application of any medical procedure. In my view, it is the wrong right a person has to kill him or herself. I have said to Fariñas that he is acting against his own physical integrity.
A doctor’s mission is to save lives; however, in a case like this we must respect the patient’s will. We can’t go against his will unless he is unconscious and his close family approves.
Could you offer more details about the care provided to Guillermo Fariñas?
This person, like every other patient here, is privileged. He is accompanied by a relative around the clock. He has a TV set where he is watching the Football World Cup, which he likes. He also has a direct telephone line, the same as every other patient in this ward. Beyond what medicine can do, these amenities are important to the spirituality of the patient.
The intensive care services are expensive worldwide. Thanks to our healthcare system, Fariñas, like every other Cuban who requires these services, is not paying a penny.
I’ve had the opportunity of working in other countries, both in underdeveloped and developed nations. I spent one and a half year in France and I could see how costly it is to keep a patient in an intensive care unit. It’s very expensive.
And, what can you tell me about the medical expertise, the equipment available and the additional tests he has had?
At this moment, the entire team of the intensive care unit is available to him. These are ten specialist doctors, half of them Second Degree Specialists in Intensive and Emergency Medicine. They are all working with Fariñas. Every day we meet and discuss his case, his condition and evolution, what to do and what may be needed in order to get it.
You have just said “what may be needed in order to get it,” and I ask you, to get it where, in this country or in other countries?
Here and in other countries. We have bought medicines for this and other cases because many medicines we need to buy from other countries.
For instance, all of the parenteral nutrients that Fariñas receives –amino acids, lipids, vitamins and trace elements—are coming from Europe. Cuba buys them not only for this patient but for other Cubans who need it. However, Fariñas is the only one that requires them because he refuses to eat.
Do you have an idea of how much the treatment provided to this patient is costing the country?
It’s practically impossible to compare the costs in Cuba with any other place. Cuban medicine is perhaps the cheapest in the world and probably the most efficient because healthcare services are not designed for profit.
What I can tell you for sure is that, in any developed country, one day in an intensive care unit costs no less than $1,300, and this does not include complementary tests and medicines. In this case, we are talking of 110 days in the unit and over 300 lab tests.
For example, we check this patient’s glycemia almost on a daily basis; 96 tests until today.
We have already treated him for four serious bacterial vascular infections which have required such antibiotics as vancomicyn, ciprofloxacin, gentamicyn and rocephyn. We have practiced 66 ionograms to measure electrolytes in blood and correct any imbalance. We calculate his 24-hours urea almost every day to assess the nitrogen used by his body and ensure an adequate balance.
We constantly monitor his system to prevent imbalances. This is what has enabled Fariñas to have a rather acceptable nutritional condition after 125 days of fasting, although the danger persists because this is not physiological, eating is.
This patient has had electrocardiograms, X-rays, ultrasounds, and multi-slice tomographies. We have conducted all the necessary studies.
You said before that the doctor-patient relation has been good. How would you describe the doctor-family relation?
I’ve talked to his mother, his wife and an uncle, as well as to some of his friends. There is a good doctor-patient relation that makes practically everything possible but eating. That is our constant request.
In sum, I think Fariñas’ and his family’s relation with the team of doctors and nurses in our services has been good. For as long as he has been here, I have not received any complains about the way he is treated. On the contrary, he always speaks of the professionalism of the doctors and he says he doesn’t want to go anywhere, although he says he has received offers to treat him abroad. However, he says he won’t go because here are the people who have saved his life. He trusts our healthcare services.
How do you describe Guillermo Fariñas’ condition at this moment?
Today, the patient faces a potential danger of dying. It depends on the evolution of that thrombus located in the jugular-subclavian left confluent, for which he is being adequately treated. I wish it dissolved; that would make it one more complication solved by our team of doctors and nurses. We shall continue doing our best to preserve his life.