Doctors should take a "considered decision" on withdrawal of life support in terminally ill patients on the basis of certain conditions including a documented informed refusal by the patient or their kin, according to draft guidelines released by the Union Health Ministry.
The guidelines laid out four conditions for passive euthanasia to take a "considered decision in a patient's best interests, to stop or discontinue ongoing life support in a terminally ill disease that is no longer likely to benefit the patient or is likely to harm in terms of causing suffering and loss of dignity."
The conditions are:
- 1. The individual has been declared to have had a brainstem death
- 2. There is medical prognostication and a considered opinion that the patient's disease condition is advanced and not likely to benefit from aggressive therapeutic interventions,
- 3. A patient/surrogate documented informed refusal, following prognostic awareness, to continue life support
- 4. Compliance with procedures prescribed by the Supreme Court.
The 'Draft Guidelines for Withdrawal of Life Support in Terminally Ill Patients,' also state that doctors should take a considered decision to not start a life supporting measure in a terminally ill patient that is unlikely to benefit the patient and is likely to lead to suffering and loss of dignity.
In such a case, three conditions — on whether the individual has been declared to have a brainstem death, if there is a medical prognostication and considered opinion that the patient's disease condition is advanced and not likely to benefit from aggressive therapeutic interventions, patient/surrogate documented informed refusal, following prognostic awareness — has to be taken into account.
The Union Ministry has invited feedback and suggestions from stakeholders on the draft guidelines by October 20, 2024.
The draft guidelines have not gone down well among a section of the medical fraternity, with the Indian Medical Association's national president R. V. Asokan stating it exposes doctors to legal scrutiny and puts them under stress.
"Such clinical decisions have always been taken in good faith by doctors. The patient's relatives are given explanations and all information, taken into confidence in a given case and a decision is taken on merit in every single case. Putting it down in guidelines and also alleging that inappropriate decisions have been taken or they have been prolonged is misunderstanding the situation," Dr. Asokan said.
"First the perception and assumption that unnecessarily machines are used and lives are prolonged is wrong. It exposes the doctors to legal scrutiny. More so what is left of a doctor-patient relationship... trying to define it in four corners of black and white documentation which is legally scrutinised is nothing but exposing the doctors to further stress," he said.
There are things which should be left to relatives, patients, and doctors based on science and the situation, Dr Asokan added.
The Indian Medical Association, Dr. Asokan said, will study the document and submit its views seeking a revision of the draft guidelines.
Terminal illness in the draft guidelines has been defined as an irreversible or incurable condition from which death is inevitable in the foreseeable future. Severe traumatic brain injury which shows no recovery after 72 hours or more is also included.
The draft document states that many patients in the ICU are terminally ill, and not expected to benefit from life sustaining treatments (LST) that include (but are not limited to) mechanical ventilation, vasopressors, dialysis, surgical procedures, transfusions, parenteral nutrition or Extracorporeal Membrane Oxygenation.
"In such circumstances, LST are non-beneficial and increase avoidable burdens and suffering to patients and therefore, are considered excessive and inappropriate. Additionally, they increase emotional stress and economic hardship to the family and moral distress to professional caregivers.
“Withdrawal of LST in such patients is regarded as a standard of ICU care worldwide and upheld by several jurisdictions. Such decisions have medical, ethical and legal considerations,” the draft said.
The draft calls for taking considered decisions on not performing cardiopulmonary resuscitation in the event of anticipated cardiac arrests if there is no realistic possibility of survival or meaningful recovery.
According to the document, the legal principles outlined by the Supreme Court state an adult patient capable of taking healthcare decisions may refuse LST even if it results in death.
Further, according to principals, LST may be withheld or withdrawn lawfully under certain conditions from people who no longer retain decision-making capacity, based on the fundamental Right to Autonomy, Privacy and Dignity.
Advance Medical Directives, or AMDs that meets specified requirements are legally valid documents. An AMD is a written declaration made by a person with decision-making capacity documenting how they would like to be medically treated or not treated, should they lose capacity.
For a patient without capacity, Foregoing of Life Support proposals should be made by a consensus among a group of at least three physicians who form the Primary Medical Board (PMB). The PMB must explain the illness, the medical treatment available, alternative forms of treatment, and the consequences of remaining treated and untreated to fully inform the surrogate.
A Secondary Medical Board of three physicians with one appointee by the Chief Medical Officer of the district must validate the decision by the PMB.
"Active Euthanasia is the intentional act of killing a terminally ill patient on voluntary request, by the direct intervention of a doctor for the purpose of the good of the patient. It is illegal in India," the draft document said.
Published - September 30, 2024 03:47 pm IST
