Dr KK Aggarwal
Advance Medical Directives
(AMD) are now legal in India following the landmark judgment of the Supreme
Court of India in the matter of “Common Cause versus Union of India, 2018 (5)
SCC 1”. The treating doctor who in good faith abides by an advance directive
will not be held liable under criminal law.
The Federation of Indian
Chamber of Commerce and Industry (FICCI) and End of Life Care in
India Taskforce (ELICIT) have come together to release an information
guide to improve and facilitate execution of end-of-life decisions for doctors
and hospital administrators.
ELICIT is a joint initiative
of the Indian Academy of Neurology, Indian Society of Critical Care Medicine
(ISCCM) and Indian Association of Palliative Care (IAPC) formed in 2015.
Here are excerpts from the
“Action Plan for end-of-life care and decision-making”.
· “Respect
a competent patient's decision: When the patient who is competent refuses
treatment this should be honored. Respecting the patient's decision is required
by the law. This decision should be respected even if the patient's family
members express a different opinion regarding Foregoing of Life Support (FLS).
· Opt
for shared decision making, if overriding an AMD is in the patient's best
interest: If the patient is
incompetent but has a valid AMD, this must be honored as far as possible. If
there are valid grounds to override the same in the best interests of the
patient, a consensus through shared-decision making should be arrived at,
between caregivers and surrogates, which should be duly documented.
· Base
the decision on wishes of the patient as well as the prognosis, when no AMD is
available: If there is no AMD
available, decisions between care givers and surrogates must be based on the
'values and wishes' of the patient as known to the family as well as the
prognosis and best interests of the patient as judged by the treating doctors.
Only under exceptional circumstances, such as when a person is in a persistent
vegetative state, can the Court-recommended procedure be implemented. For
example, in a case of terminal cancer with imminent death, decision not to put
the patient on a ventilator needs to be taken within hours or few days. In the
common scenario, the FLS decisions must be based on refusal of consent for
either initiation or continuation of life sustaining treatment in such cases.
All decisions must also be duly documented to ensure transparency.
· Certify
and document Brain Death in accordance to the Transplantation of Human Organs
and Tissues Act, 1994: Brain death
should be certified and documented in the manner laid down in the
Transplantation of Human Organs and Tissues Act, 1994 irrespective of whether
there is consent for organ donation or not. This is in conformity with
internationally accepted definitions of death. This position in Law was further
reiterated in the Aruna Shanbaug judgement. When brain death has been so
certified, the patient can be disconnected from life support unilaterally after
informing and counselling the family.”
The Transplantation of Human
Organs and Tissues Act, 1994 has defined a "deceased person" as a
person in whom permanent disappearance of all evidence of life occurs, by
reason of brain-stem death or in a cardiopulmonary sense, at any time after
live birth has taken place
(Source: FICCI-ELICIT
information guide to facilitate execution of end-of-life decisions - for
Doctors and Hospital Administrators)
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of
India
Past National President
IMA
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