NEW DELHI: Life support can be withdrawn from a terminally ill patient if both the primary and secondary medical boards constituted by a hospital, as well as the family or surrogate of the patient, give their consent, the health ministry has suggested.
In draft guidelines released for public comment, the ministry states that many patients in ICUs are terminally ill and are not expected to benefit from life-sustaining treatments (LST), which include (but are not limited to) mechanical ventilation, surgical procedures, parenteral nutrition, and extracorporeal membrane oxygenation (ECMO).
"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," the ministry says.
Terminal illness refers to an irreversible or incurable condition from which death is inevitable in the foreseeable future. Severe devastating traumatic brain injury which shows no recovery after 72 hours or more is also included.
According to the health ministry's draft guidelines, life support can be withdrawn if a patient is brain dead or prognosis suggests she or he is not likely to benefit from aggressive therapeutic interventions or in case the patient/surrogate has documented informed refusal, following prognostic awareness, to continue life support.
A surrogate is a person or persons other than the healthcare providers who is/are accepted as the representatives of the patient's best interests, who will make decisions on behalf of the patient when the patient loses decision-making capacity. If the patient has made a valid advanced medical directive (AMD), the surrogate would be the person or persons named in the directive. If there is no valid AMD, the surrogate will be the next of kin (family) or the next friend or guardian (if any) of the patient.
According to govt guideline, the primary medical board (PMB) which has to assess inappropriateness of life support should consist of the primary physician and at least two subject experts with at least five years of experience. After that, the decision is to be verified further by the secondary medical board (SMB) which should consist of one registered medical practitioner (RMP) nominated by the CMO and at least two subject experts. A member of the PMB cannot form part of the SMB. Additionally, govt guidelines suggest, the hospital may constitute a clinical ethics committee of multi-professional members for audit, oversight and conflict resolution.
Dr R K Mani, one of the doctors involved in drafting the guidelines, told TOI that the last date for submission of comments is Oct 20. "Any issues raised will be addressed by the expert group on behalf of the health ministry," he said.
Dr Sumit Ray, head of critical care department at Holy Family hospital , said, "The Supreme Court, in its wisdom, has placed the safety of the individual as the highest priority, but that unfortunately has made the process very complex and complicated and difficult to implement. But, it is surely a step forward and hopefully it will be reviewed in the near future after some experience with this process, to make it smoother and less complex, while continuing to maintain the autonomy and safety of the patient and the wishes of the family in mind," he said.
In draft guidelines released for public comment, the ministry states that many patients in ICUs are terminally ill and are not expected to benefit from life-sustaining treatments (LST), which include (but are not limited to) mechanical ventilation, surgical procedures, parenteral nutrition, and extracorporeal membrane oxygenation (ECMO).
"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," the ministry says.
Terminal illness refers to an irreversible or incurable condition from which death is inevitable in the foreseeable future. Severe devastating traumatic brain injury which shows no recovery after 72 hours or more is also included.
According to the health ministry's draft guidelines, life support can be withdrawn if a patient is brain dead or prognosis suggests she or he is not likely to benefit from aggressive therapeutic interventions or in case the patient/surrogate has documented informed refusal, following prognostic awareness, to continue life support.
A surrogate is a person or persons other than the healthcare providers who is/are accepted as the representatives of the patient's best interests, who will make decisions on behalf of the patient when the patient loses decision-making capacity. If the patient has made a valid advanced medical directive (AMD), the surrogate would be the person or persons named in the directive. If there is no valid AMD, the surrogate will be the next of kin (family) or the next friend or guardian (if any) of the patient.
According to govt guideline, the primary medical board (PMB) which has to assess inappropriateness of life support should consist of the primary physician and at least two subject experts with at least five years of experience. After that, the decision is to be verified further by the secondary medical board (SMB) which should consist of one registered medical practitioner (RMP) nominated by the CMO and at least two subject experts. A member of the PMB cannot form part of the SMB. Additionally, govt guidelines suggest, the hospital may constitute a clinical ethics committee of multi-professional members for audit, oversight and conflict resolution.
Dr R K Mani, one of the doctors involved in drafting the guidelines, told TOI that the last date for submission of comments is Oct 20. "Any issues raised will be addressed by the expert group on behalf of the health ministry," he said.
Dr Sumit Ray, head of critical care department at Holy Family hospital , said, "The Supreme Court, in its wisdom, has placed the safety of the individual as the highest priority, but that unfortunately has made the process very complex and complicated and difficult to implement. But, it is surely a step forward and hopefully it will be reviewed in the near future after some experience with this process, to make it smoother and less complex, while continuing to maintain the autonomy and safety of the patient and the wishes of the family in mind," he said.
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