Right to Advance Will and to forego life support: A Landmark judgement

Dr RK Mani, Group CEO, Nayati Group of Hospitals, Mathura, Agra and Amritsar

We must laud a truly Landmark judgment. The Supreme Court in a 5-Judge Constitutional bench delivered a judgment that is crucial to protecting patient’s rights towards the end of life: the right to Advance Will and the right to passive euthanasia. This judgment also decriminalizes well-meaning physicians and families who take decisions to withhold or withdraw life support in response to patient’s autonomous choice towards the end of life.

The petition was filed by an NGO Common Cause in 2005. I had impleaded in this case on behalf of the Indian Society of Critical Care Medicine (ISCCM). To me personally and to my colleagues in Intensive care, Palliative care and Neurology and many legal experts (as a part of an Advocacy group End of Life care India Task force (ELICIT)), it was a moment of vindication of our campaign to restore and respect our individual freedoms. The Supreme Court has recently delivered two progressive judgments that would go a long way in humanizing healthcare: the Privacy judgment last year and this one on Advance Will and Passive euthanasia.

Why is it so important?

In a doctor-patient relationship autonomy and Beneficence are crucial. Autonomy is to have control over what is done to your body even if you should lose mental capacity either through an instrument such as Advance Will or through surrogates. Beneficence is the obligation of the physician to act to the benefit and “best interests” of the patient always. Going against patient’s informed wishes would violate this principle. Professional ethics makes it mandatory that we respect patient’s choice to forego life support when it is likely to benefit only a little but potentially could do great harm. The CJI and his colleagues observed that the principle to forego prolongation of life in the context of terminal illness is consistent with religion and philosophy. He also observed medical decisions must also integrate socio cultural and economic considerations. For the first time we hear from the SC these fundamental principles that have been subjects of much debate and deliberations all over the world. End of life issues have been a part of mainstream medical research for the last three decades. 

The ISCCM formulated ethical position statements in 2005, 2012 and together with the Indian Association of Palliative Care (IAP) in 2014, based on these principles and evidence basis in world literature. It had outlined the practical steps by the bedside focusing on alleviation of pain, dyspnoea and distress. The principles embodied in the position statements stand endorsed by the present legal pronouncements. The terminology employed by the SC remains somewhat outdated in relation to contemporary medical usage. Recently under the aegis of the ICMR a document called “Definition of terms used in limitation of treatment and providing palliative care at end of life “ is ready to be released this month. This would go a long way in standardizing the terms used to facilitate communication and formulation of precise rules.

The work towards compassionate care of the dying is unfinished. The court has removed the requirement for a Court procedure for “Passive euthanasia” decisions mandated in the Aruna Shanbaug case. This is removal of what appeared to be an insurmountable road block. The CJI during court proceedings had observed that neither the family nor the physician looking after a terminally ill patient would have the time to approach the High Court!

The details may carry the devil unless the medical profession fully participates in its formulation. There should be adequate safeguards which should be pragmatic and not obstructive of decisions to forego life support. This is because as an intensivist I know these are every day decisions that would serve to avoid an immense load of medical technology imposed suffering.

The fear of the Law that has kept many of us from making ethical decisions will now be lifted. Such decisions will go a long way in bridging the trust deficit between doctors and patients. There is nothing more healing than a dose of humane care.

Supreme Court allows ‘living will’

Dr KK Aggarwal

Recipient of Padma Shri

In a landmark judgement delivered today, the Supreme Court of India has allowed an individual to draft a living will specifying that they not be put on life support if they slip into an incurable coma.

The order was passed by a five judge Constitutional bench comprising Chief Justice of India (CJI) Dipak Misra and Justices AK Sikri, AM Khanwilkar, DY Chandrachud and Ashok Bhushan, which said “Human beings have the right to die with dignity.” 

Though the judges gave four separate opinions, all of them were unanimous that a 'Living Will' should be allowed, because an individual should not be allowed to continue suffering in a vegetative state when they don't wish to continue living, and know fully well that they will not revive. The Apex Court has set forth strict guidelines on how to execute the mandate of the living will.

Four terminologies need to be understood in context of this judgement: Advanced directive, living will, health care proxy and DNR.

Advance directive: This is a legal document made when the person is alive and still in possession of decisional capacity about how treatment decisions should be made on her or his behalf if they are no longer able to make decisions for themselves or lose the capacity to make such decisions. Advanced directives are acted upon only when the patient has lost the ability to make decisions for himself. They can be revoked orally or in writing by the patient at any time (so long as he or she has maintained decisional capacity).

Advanced directive is a Durable Power of Attorney for Health Care (DPAHC or Health Care Proxy) and living will.

Living will: A living will is a document that summarizes a person’s preferences for future medical care including specific interventions such as cardiopulmonary resuscitation (CPR), ventilatory support, or enteral feeding. It is a document in which patients give clear instructions about treatment to be administered or state their wishes for end-of-life medical care, when they are no longer able to communicate their decisions. A living will takes effect when the person is terminally ill without chance of recovery, and outlines the desire to withhold heroic measures.

Health care proxy: A health care proxy is a person identified by the patient who will take decision with regard to treatment on his/her behalf in case he/she is incapacitated. Simply put, it can be likened to giving “power of attorney” but for medical decisions.

DNR or Do not resuscitate:  This document applies specifically to cardiopulmonary arrest and not to the current health status, even when the patient becomes progressively more ill. It indicates whether the patient wishes for all efforts to be made to revive him by CPR and to be put on lifesaving ventilator.

The American Heart Association recommends that all patients in cardiac arrest should be resuscitated unless they have a valid DNR order, or in cases where resuscitation is physiologically futile (signs of irreversible death).

A series of workshops and guidelines have discussed end of life choices. It was also discussed at ‘End of Life Care’ CMAAO meeting in Tokyo, Japan in September 2017. Active euthanasia was given a big ‘no’ at this meeting, while with regard to withdrawal of ventilation, two options were suggested: either do not put the patient on ventilator or remove the ventilator.

In its Position Statement on End of Life Care and Advance Care Planning, the American Medical Association (AMA) advocates that advance care planning become part of routine clinical practice so that patients’ wishes and preferences for health care, particularly end of life care, are known and met. AMA further says, “The planning process respects the patient’s right to take an active role in their health care, in an environment of shared decision-making between the patient and doctor. It may involve family members, religious advisors, friends and other people the patient feels should be involved.” However, “an advance directive never takes precedence over the contemporaneous wishes of a patient who has decision-making capacity.”

Advance care planning is also considered a routine part of a person's health care in Australia, which allows competent patients the right to make their own decisions involving the withholding and/or withdrawal of life-sustaining treatment

However, the complete judgment needs to be read to fully understand its implications in practice.

In its judgement in Aruna Shanbaug case, the Supreme Court had permitted passive euthanasia for a patient in permanent vegetative state, provided it had the approval of the High Court.

“Hence, even if a decision is taken by the near relatives or doctors or next friend to withdraw life support, such a decision requires approval from the High Court concerned as laid down in Airedale's case (supra). In our opinion, this is even more necessary in our country as we cannot rule out the possibility of mischief being done by relatives or others for inheriting the property of the patient.”

“132. In our opinion, in the case of an incompetent person who is unable to take a decision whether to withdraw life support or not, it is the Court alone, as parens patriae, which ultimately must take this decision, though, no doubt, the views of the near relatives, next friend and doctors must be given due weight.”

The judgement of the Supreme Court does not answer the question as to who will take the decision to withdraw or remove the ventilator if there is no living will.

The current practice (though not legal) is that all legal heirs sign a document for DNR or withdrawal. 

Read the Complete Judgment: http://supremecourtofindia.nic.in/supremecourt/2005/9123/9123_2005_Judgement_09-Mar-2018.pdf

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

IMA Mahapanchayat on 25th March at Delhi

Dr KK Aggarwal 

For over three years now, the Indian Medical Association (IMA) has been fighting for the legitimate demands of the medical profession. And, each movement has been bigger than the previous.

The “Dilli Chalo” movement on the 6th of June last year to this end was a historical success and a milestone in the history of IMA. It was the biggest ever spontaneous congregation of doctors from all corners of India. In a follow-up to the Dilli Chalo movement, a dawn-to-dusk fast was observed throughout the country on October 2, 2017, the birthday of Mahatma Gandhi.

Carrying the momentum forward to this year, IMA is organizing a one-month program, wherein the IMA National President Dr Ravi Wankhedkar is on a one month Yatra, which started at Kanyakumari on 25^th February and will culminate in the Doctors’ Mahapanchayat in New Delhi on 25^th March, when thousands of doctors will gather for the Doctors’ Mahapanchayat in New Delhi at Indira Gandhi Stadium.

IMA has planned a cycle rally on 11^th of this month as a pan-India activity, where all IMA members across the country will be on the roads on cycles, scooters, motor bikes to raise awareness about health under the theme “Health First”. And also to make the public aware as to why IMA is opposing the National Medical Commission (NMC) Bill in its present format.

There are two ways to fight for our rightful demands. One is by way of agitation, and the other is a peaceful protest.

All this time, IMA has been peacefully asking for its rights, the Gandhian way, except for a nation-wide 12-hour flash strike on 2^nd January this year to protest against the NMC Bill. This strike was called off after the proposed NMC Bill was referred to a parliamentary standing committee.

The objective of IMA is to cross the collective consciousness. There are more than 10 lakh doctors in the country and IMA represents 30% of these doctors, which is beyond the critical mass of collective consciousness of doctors, 1% of 10 lakh i.e. 10,000 doctors only.

Incidents of violence against doctors are increasing. Instead of amending the IMC Act, the govt. is introducing the NMC, which replaces the MCI with another body, the National Medical Commission. It is taking away our professional autonomy.

The govt. is not implementing suitable amendments in CEA and PNDT Act. Criminal prosecution of doctors in clinical practice and allowing non-MBBS, non-BDS doctors to practice modern medicine via a Bridge course are other major issues that IMA is fighting for.

One call of IMA achieved the critical mass on 2nd January. One voice of IMA can paralyze healthcare services; however, this is not the intention of IMA as is evident from the various movements of IMA in this regard. The welfare of the patients are foremost for us.

The public should join hands with IMA to fight these issues as they are anti-people and anti-poor. All professional and non-professional associations and organizations should also join hands with IMA as they may face a similar situation sooner or later.

It is only through the timely and persistent efforts of IMA that the NMC Bill was referred to the Parliamentary Standing Committee.

If the Bill goes through in its present format, the govt. will exercise control over the medical profession and we would be answerable to bureaucrats and others nominated members, with no medical background.

The Bill promotes crosspathy. Allowing Ayush doctors to practice modern medicine after just a 6-month Bridging course, can put the life of the patient in danger as they may not be able to accurately diagnose an emergency condition and give timely and appropriate first aid. This is also violates the MCI Code of Ethics Regulations, which allow only a doctor having qualification recognized by MCI and registered with Medical Council of India/State Medical Council to practice modern system of medicine or surgery (1.1.3).

The Bill also allows private medical colleges to fix charges for up to 60% of seats paving the way for ensuing corruption.

The issues that IMA has been raising concern every doctor in the country. There is a lot at stake here – public health and welfare, which may be put in harm’s way by the proposed unscientific mixing of pathies; we are on the verge of losing our professional autonomy.

We must not lose momentum and focus. These movements must continue till our goals are achieved.

I appeal to all doctors to participate wholeheartedly in these movements.

Let’s all be on the road on 11^th March and also gather in large numbers at Indira Gandhi Stadium in a show of strength and solidarity.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Newer technology is not necessarily better than its predecessor

The impact of technology has percolated through almost every corner of our lives in the past few years. The advent of social media has revolutionized communication.

Medicine too has benefited tremendously from the advances in technology, which have made it easier to practice medicine. Doctors are now better equipped to diagnose and manage their patients. But on the flip side of it, there is a pressure to keep up with the rapidly changing and advancing technology. The older version then becomes outdated and may even be publicized as that.

We don’t buy a new computer every year or for that matter, an ultrasound, or an echocardiography machine or CT scan every year.

Whenever a new technology is introduced in the market, we face a dilemma whether to acquire the latest version or not.

Any new advancement in technology definitely comes with some improvements or some new features.

But just because something is new, does not mean that it is better. Newer technology is not necessarily better than its predecessor or its earlier version.

For instance, most advances in Echocardiography machine may help the echocardiographer by making diagnosis easy, but may not offer any additional advantage to the patient.

Newer stents may be easy to maneuver, but may be required in only 1-2% of cases. And, in the hands of an experienced interventional cardiologist, this may not even matter.

Any technology lasts for 6-10 years. This means that spares and service will be available for this period of time.

Earlier, technological advances came to India 6-10 years late, but now they happen parallel to those in the West. But this does not mean that one should shift to the newer technology, each time it is introduced.

A stent which is available today cannot be outdated tomorrow.

Availability, accessibility and most importantly, affordability are key concerns in health care delivery, especially in a country like ours. Hence, focus should not be just on the acquisition of the newer technology.

For the large majority of the population, affordable health care means anything introduced in the last 6-10 years, but with the caution that it is not banned or prohibited in terms of safety. Effective use of technology, clinically as well as in terms of cost, will make health care more affordable and accessible and ensure best care possible for patients.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

We wish Irrfan Khan the best

On Monday, noted actor Irrfan Khan shared that he is suffering from a rare disease, although there is no conclusive diagnosis yet as tests are still ongoing.

A rare disease can be diagnosed or undiagnosed. 

Our body is the largest pharmaceutical armamentarium in the world and has the capacity to heal each and every disease and has the capacity to produce any drug. This is based on the fact that no drug acts in the body without a receptor. If there is no receptor in the body, the drug will not work. The very fact that there is a receptor for every drug in the body means that the body has the capacity to produce that drug.

In the wave particle duality theory of quantum physics, this capability of the body lies in the wave part. This power of the body, which supplements modern medicine, can be enhanced by meditation and prayer, specifically, collective meditation and collective prayers. In the parasympathetic mode or the undisturbed state of consciousness, the body can help form any drug.

When Amitabh Bachchan fell critically ill following a near-fatal abdominal injury sustained while shooting for the film ‘Coolie’, the entire country had prayed for his recovery. The collective prayers worked their miracle and he recovered. In any temple, idol pratishthan also acts like an antenna or tower, which receives all waves.

The purpose of life is a good quality of life with a combination of modern medicine and the blessings of the society. 

Receiving a diagnosis of a serious illness can cause acute anxiety or acute depression.

Disclosing illness to others is a personal decision. Sharing the news of his illness on social media has connected Irrfan Khan to millions across the world. It will help connect the quantum waves of millions to his quantum wave to find a solution. 

This does not mean just their good wishes, it also means support from people who may be similarly afflicted. It also means support from people who are experts, doctors, who can offer professional help.

Many politicians and celebrities choose to hide their illness from the public. There can be many reasons for not disclosing their illness. Fear of repercussions in political circles, loss of power and prestige may be the reasons for some. However, as per Vedic science, hiding an illness does not make sense. Instead they should become brand ambassadors of that disease.

To Irrfan Khan, I would like to say that the prayers of the entire country, especially doctors, are with you. We all wish you the best….Maybe there is a miracle waiting to happen.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Controlling noise pollution: Always try speaking in a minimum audible volume

  

Dr KK Aggarwal, Padma Shri Awardee

As per guidelines, the permissible noise levels in residential areas is 45 dB in night time and 55 dB in day time. Permissible noise limits in Silence zones are 50 dB in daytime (6am to 10 pm) and 40 dB in night time (10 pm to 6am). Silence zone is referred as areas up to 100 meters around such premises as hospitals, educational institutions and courts.

In the last three years, I have checked noise levels in CMEs organized by various bodies and found them to between 60 and 100 dB. For a proper attention span, the noise levels should be below 50 dB.

If a mike is used in a conference hall, the background noise level is more than 50 dB. Noise from other rooms, hallway noises, or noise within the hall itself such as conversation of the audience, noise from AC/fans, phones ringing, turning paper, etc. adds to the decibels. Background noise interferes with auditory communication and adversely affects speech perception and speech recognition. It also affects attention and memory.

One can tolerate exposure to 80 dB for up to 8 hours in a day; 85 dB for 4 hours; 90 dB for 2 hours; 95 dB for one hour; 100 dB for 30 minutes; 105 dB for 15 min and 110 dB for less than a minute without adequate sound protection.

People shout at each other in anger, but speak softly when expressing love. The distance remains the same, it’s the tone of the speech, which changes.

Exposure to noise beyond permissible levels is a health hazard. Noise shifts the body to sympathetic mode and takes us away from conscious-based decisions. Hence, we should make an effort to speak softly to minimize the ambient noise levels.

Vedic literature has described four gradations or levels of sound: Para (background noise of nature, no spoken sound), pashyanti (observed sound or perceived in mind), madhyama (audible sound), and vaikhari (articulated sound or spoken words). We should speak in Pashyanti and madhyama.

A national workshop Noise and Health was organized on Sunday at Hotel Le Meridian for Safe Sound initiative of IMA as part of the National Initiative for Safe Sound (NISS). The workshop was inaugurated by IMA National President Dr Ravi Wankhedkar. Dr John Panicker was the National Co-ordinator. Through this initiative, IMA has entrusted itself with the responsibility of achieving noise pollution free India.

According to new estimates released by WHO on the occasion of World Hearing Day on March 3, around 900 million people could suffer from disabling hearing loss by 2050. Exposure to loud sounds through personal audio devices and in entertainment venues and workplaces is a major factor contributing to the rising prevalence of hearing loss.

All of us are now used to mikes in class rooms or lecture halls or DJ music.

Instead, ask the audience “Am I audible?” If you are audible without mike, then don’t use a mike. When I spoke in the IMA NISS workshop, I did so without using a mike.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Rational use of blood: Jaroorat bhi hai kya?

RBC transfusions are now decreasing in hospitals in the US after steadily increasing for more than 2 decades. "From 2011 to 2014, statistically significant reductions in RBC transfusions were seen among all sexes, race/ethnicities, patient risk severities, payer types, and admission types," Ruchika Goel, MD, MPH, from the Department of Pathology at Weill Cornell Medical College in New York City, and colleagues wrote a large, population-based report published in JAMA.

More hospitals have launched blood management programs to restrict transfusions.

The percentage of hospitalized patients who received RBC transfusions decreased from a peak of 6.8% in 2011 to 5.7% in 2014. At the same time, the proportion of patients who received a plasma transfusion went from 1.0% in 2011 to 0.87% in 2014.

Among elective admissions, the relative decline in RBC transfusions was significantly larger (26%) than for nonelective admissions (14%).

Human blood is covered under the definition of “Drugs” under Section 2(b) of Drugs and Cosmetics Act.

All over the world, there is a movement for rational use of drugs. So, when we talk of rational use of drugs, blood and blood products are a part of the discussion. This is how you can do it.

• Transfuse blood only when it is required.
• If only one unit is required, avoid transfusing blood
• If two units are required, transfuse one.
• If hemoglobin is more than 7, give a trial of intravenous iron first.
• All elective surgeries should be given IV iron to build up hemoglobin preoperatively. Not doing so may mean deficiency in service.
• Autologous blood transfusion is another answer.
• NABH should consider rational use of blood transfusion as one of the criteria in accreditation of a hospital. A good hospital is one which uses minimum blood transfusions.

If hospitals in the US can reduce blood transfusions, why can’t we?