🍸Should a critically ill person have the right to die on their own terms? This is one of the most debated topics in modern healthcare. In recent years, the Supreme Court has recognised the right of terminally ill patients to die with dignity. However, India does not have any formal legislation on the actual processes for facilitating this right.
In September 2023, the Union Health Ministry released draft guidelines on passive euthanasia, titled "Guidelines for Withdrawal of Life Support in Terminally Ill Patients."𓆏 Passive euthanasia means withdrawing or withholding life support. While withdrawing life support means stopping a treatment that is no longer helping the patient, withholding life support means not starting a treatment at all. This differs from active euthanasia, which involves deliberately administering a fatal dose of drugs to cause death.
🍃The draft advises doctors to make a "considered decision" regarding the withdrawal of life support for terminally ill patients. Terminal illness in the draft guidelines has been defined as an irreversible or incurable condition from which death is inevitable in the foreseeable future. If implemented, these guidelines would establish a legal and regulatory framework that has been absent until now.
🌌Formulated by experts from AIIMS, the guidelines allow patients to make an informed decision on whether to continue life support and whether they wish to be resuscitated. They also allow for the withdrawal of supportive care, including ventilation, dialysis, or ECMO.
ᩚᩚᩚᩚᩚᩚᩚᩚᩚ𒀱ᩚᩚᩚThe withdrawal of life support can be done under the four conditions:
♒The individual must be declared brain stem dead as per the Transplantation of Human Organs (THOA) Act.
🍌Medical prognostication must indicate that the patient’s condition is advanced and unlikely to benefit from aggressive therapeutic interventions.
♍The patient or surrogate must document an informed refusal, following prognostic awareness, to continue life support.
✅There must be compliance with procedures prescribed by the Supreme Court.
൲This is applicable for patients who are terminally ill and are not expected to benefit from life-sustaining treatments, such as mechanical ventilation, vasopressors (drugs that increase blood pressure by constricting blood vessels), dialysis, surgical procedures, transfusions, parenteral nutrition (intravenous feeding outside the digestive tract), or extracorporeal membrane oxygenation (ECMO, a machine that helps the heart or lungs function in critically ill patients), according to the draft guidelines.
ꦉThe guidelines further state that in such cases, life-support systems provide no benefit and only add avoidable burdens and suffering for patients and hence are considered excessive and inappropriate. These treatments also contribute to emotional stress, economic hardship for families, and moral distress for healthcare professionals. Hence, the withdrawal of life-support treatments in such patients is regarded as a standard of ICU care worldwide and has been upheld by several jurisdictions, the draft guidelines say.
🦄Once a physician deems life-sustaining measures inappropriate, the case will be referred to the primary medical board. If the board reaches a consensus, a multidisciplinary meeting will take place with the family to make a shared decision. For cases involving the forgoing of life-sustaining treatments, the case will be referred to a secondary medical board, and the withdrawal of support will occur only after their approval.
🉐The draft guidelines have faced criticism from the medical community. According to Dr R.V. Asokan, president of the IMA, the proposed draft guidelines put undue pressure on clinicians and may expose them to increased litigation by families of terminally ill patients.
"Such clinical decisions have always been taken in good faith by doctors. The patient's relatives are explained and given all information, taken into confidence in a given case and decision is taken on merit in every single case. Putting it down in sort of guidelines and also alleging that inappropriate decisions have been taken or they have been prolonged is misunderstanding the situation," Dr. Asokan said, as quoted by news agency PTI.
💦"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 situation, Dr. Asokan said.
This is not the first time passive euthanasia has been debated in India. Although India does not have formal legislation on the matter, the Supreme Court 🐼recognised the legality of passive euthanasia in 2011 following the case of Aruna Shanbaug, a nurse at KEM Hospital in Mumbai who had been in a vegetative state for 42 years.
🐟In 2018, the Supreme Court legalised passive euthanasia, contingent on the existence of a "living will." A living will is a document that specifies the actions to be taken if a person is unable to make their own medical decisions in the future. The Court ruled that the "right to die with dignity" is part of the right to life under Article 21 of the Constitution of India.
