Enhancing Advance Care Planning in India through a 12-step Pathway

Abstract

Background

Advanced care planning (ACP) and advance medical directives (AMDs) are vital for aligning medical decisions with patient preferences, particularly for end-of-life care. The 2018 Supreme Court judgment in India established the legality of AMDs, enabling patients to exercise their autonomy. Recent amendments in 2023 simplified procedural requirements, replacing judicial magistrate approval with a streamlined two-tier medical board system. This article proposes a culturally sensitive and practical 12-step framework for implementing ACP and AMDs in India.

Materials and methods

A structured and consensus-driven process was undertaken by experts in palliative medicine, neurology, critical care, and geriatrics, supported by key medical organizations. The development process included multiple iterations, public consultations, and feedback from legal and medical stakeholders. The framework integrates legal, ethical, and cultural considerations to address procedural and systemic challenges in ACP implementation.

Results

The proposed 12-step pathway focuses on three phases: creating living wills, periodic reviews and updates, and executing AMDs. Key components include initiating discussions, identification and appointment of surrogate decision-makers, ensuring legal compliance through simplified procedures, and providing guidance for withholding or withdrawing life-sustaining treatments. Implementation strategies emphasize public awareness, provider training, and institutional policies to normalize ACP. Simplified legal requirements introduced in 2023 facilitate broader adoption and reduce procedural barriers.

Conclusion

This framework provides a practical, culturally relevant model for ACP in India, ensuring patient-centered, ethical, and transparent end-of-life care. By integrating simplified legal procedures and addressing misconceptions through education and policy initiatives, the proposed approach empowers individuals, families, and healthcare providers to make informed decisions, fostering dignity and autonomy in medical care.

How to cite this article

Damani A, Ghoshal A, Rao K, Nair S, Gursahani R, Simha S, et al. Enhancing Advance Care Planning in India through a 12-step Pathway. Indian J Crit Care Med 2025;29(4):301–307.

Highlights

Advanced care planning (ACP) and Advance Medical Directives (AMDs) empower patient-centered end-of-life care. Following India's 2018 Supreme Court ruling and 2023 procedural simplifications, this article proposes a 12-step culturally sensitive framework to implement ACP and AMDs, emphasizing ethical, legal, and practical considerations for broader adoption.

Introduction

In 1950, India adopted its Constitution, embedding the principles of liberty, equality, fraternity, and justice, inspired by the ideals of the French Revolution.¹ These values formed the bedrock of India's governance and societal framework. Over time, the concept of liberty has evolved to encompass personal domains, particularly healthcare decision-making. A landmark development in this trajectory occurred on March 9, 2018, when the Supreme Court of India affirmed the constitutional right to autonomy over medical decisions under Article 21.² This ruling recognized advance medical directives (AMDs) as essential to uphold the right to a dignified life, empowering patients to express their preferences for end-of-life care and enabling physicians to act lawfully in alignment with these directives.^3,4 The judgment underscored the need for structured processes that respect patient autonomy while ensuring ethical and legal compliance.

Globally, the implementation of AMDs reflects diverse cultural and societal norms. In Western countries, autonomy often emphasizes individual rights, aligning with the principle of “negative freedom,” which advocates liberty free from external interference.⁵ In contrast, the Indian concept of autonomy, or Swadharma, integrates personal choices with broader social responsibilities.⁵ This divergence highlights the unique challenges of incorporating AMDs into India's healthcare system. While medical ethics balances autonomy and beneficence for patients capable of rational decision-making, the trust deficit between governance structures and the public in India poses significant hurdles to implementing AMDs.⁶ Robust oversight mechanisms are crucial to balance patient autonomy with safeguards against potential misuse.⁷ Hence, even in the presence of an AMD, the Supreme Court of India recommends a “shared decision-making” process with the designated surrogate.³

In India, cultural and structural factors complicate the adoption of AMDs. Challenges include the absence of universal health coverage, mistrust in healthcare systems, and a collective approach to decision-making that often places family at the center of end-of-life decisions. However, rapid urbanization and shifting family dynamics necessitate more individualized approaches, making ACP increasingly relevant.⁸ While the 2018 Supreme Court ruling marked a progressive step, procedural complexities—such as the requirement for judicial magistrate involvement—limited the practical implementation of AMDs. The 2023 Supreme Court amendments significantly addressed these barriers by introducing a streamlined two-tier medical board review system, replacing judicial approval, and improving accessibility.³

India's history of developing end-of-life care guidelines further contextualizes the implementation of ACP. The Indian Society of Critical Care Medicine (ISCCM) published the first guidance document integrating palliative care into ICUs in 2005, updated it in 2012, and collaborated with the Indian Association of Palliative Care (IAPC) in 2014 to release comprehensive guidelines.^9–11 These 2014 guidelines have since served as a cornerstone for subsequent frameworks, influencing the Federation of Indian Chambers of Commerce and Industry and the Blue Maple initiative.^12,13 The ICMR's guidance, meanwhile, specifically addressed DNAR directives independently of broader guidelines. The 2024 ISCCM-IAPC position statement represents a significant update, incorporating recent legal developments and expanding on the principles established in earlier documents.¹⁴

We have emphasized the novelty of the framework, explicitly stating that while ACP and AMDs have been explored globally, this is the first structured 12-step framework tailored to India's legal, ethical, and cultural landscape. We highlight how our model aligns with the 2023 Supreme Court amendments and addresses procedural barriers to implementing ACP effectively. Our goal was to produce an updated document that explains the process of ACP, AMDs, or living wills and decisions to withdraw/withhold life-sustaining treatments to ensure that it honors the patient's care preferences and values for end-of-life care. The objectives of this document include outlining a practical pathway for ACP and AMDs in India, providing an implementation strategy for ACP, and raising awareness about ACP and AMDs among healthcare providers, legislators, administrators, policymakers, the legal community, courts, and the public.

Materials and Methods

The preceding work on this document was created by the End-of-Life Care Commission, led by the Bioethics Unit of the Indian Council of Medical Research (ICMR). The core group authoring this document included palliative medicine, neurology, critical care, and geriatrics experts. This effort received support from the Indian Association of Palliative Care, the Indian Academy of Neurology, and the Indian Society of Critical Care Medicine. The core group of experts was selected based on their experience, geographic representation across India, publication history, and citation records. These experts took part in a modified Delphi process outlined in a previous publication, and their responses were kept anonymous to prevent group bias. The final document went through multiple iterations and received controlled feedback. The core group's final draft was made available on the ICMR website for public comment and suggestions. Additionally, it was shared with ethicists, legal experts, social scientists, and consumer representatives for their input. The core group thoroughly discussed all suggestions and comments and incorporated them into the document through consensus.¹⁵

Results and Recommendations

The Indian ACP pathway was developed through a structured and consensus-driven process, resulting in a comprehensive 12-step framework to address gaps in understanding and implementing AMDs in India. The framework emphasizes a practical approach to documenting and executing end-of-life care preferences while ensuring ethical compliance and sensitivity to individual values. The pathway is divided into 3 phases (Box 1).

Box 1: The proposed 12-step Indian advance care planning pathway

Creation of the living will

Step 1: Initiation of the advance care planning discussion by the healthcare providers

Step 2: identification and appointment of surrogate decision-makers

Step 3: Documentation of the wishes and preferences

Step 4: Documentation of the binding refusals

Step 5: Witnessing the living will

Step 6: Registration of the living will

Step 7: Dissemination of the living will

Review of the living will

Step 8: Periodic review and modification of the living will

Execution of the living will

Step 9: Identification of the situation needing implementation of living will

Step 10: Determination of the person's capacity to make healthcare-related decisions

Step 11: Review of the living will by the medical board

Step 12: Implementation of living will

Steps 1–7 outline the process of creating the living will. Step 8 highlights the importance of periodic review of AMDs to reflect any changes in health status or preferences. Steps 9–12 focus on executing the living will, including clear protocols for withdrawing or withholding life-sustaining treatments and providing legal and ethical guidance to ensure adherence to the patient's documented wishes.

Step 1: Initiation of the ACP Discussion by the Healthcare Providers

When a healthy individual voluntarily requests information about ACP, clinicians should clearly explain the process, focusing on the individual's values and preferences. Discussions should address how they wish to communicate their care decisions and include guidance on involving surrogate decision-makers. These conversations should be conducted privately and respectfully, ensuring the individual feels supported and informed.

Clinicians should proactively initiate ACP discussions for patients whose health conditions are anticipated to worsen or whose life expectancy may be limited. These conversations should be tailored to the patient's medical, social, and cultural context, emphasizing effective communication to explain care options clearly. Clinicians should explore the patient's preferences, involve surrogate decision-makers when appropriate, and ensure discussions are empathetic and private to align care plans with the patient's goals and values.

Step 2: Identification and Appointment of Surrogate Decision-makers

A surrogate decision-maker, also known as a healthcare proxy or healthcare power of attorney, is an individual appointed to make healthcare decisions for someone who has lost decision-making capacity. The surrogate ensures that the person's healthcare choices reflect their values, preferences, and prior instructions, safeguarding the individual's autonomy even when they cannot make decisions themselves.

The appointment of a surrogate must be documented, specifying their authority, the types of decisions they can make, and a hierarchy if multiple surrogates are designated. This documentation must align with the legal framework for surrogate decision-making. Without a documented surrogate, the next-of-kin hierarchy will apply as outlined in the 1994 Transplantation of Human Organs Act.

Surrogates must act in the patient's best interest, considering all relevant circumstances without discrimination, respecting the patient's beliefs and values, and consulting family members about previously expressed preferences. Collaboration with the clinical team is essential to ensure ethical decisions are consistent with the patient's wishes. Surrogates must avoid decisions based on subjective judgments of quality of life or any intent to hasten the patient's death.

Step 3: Documentation of the Wishes and Preferences

Advance medical directive (AMD) is a legally recognized document that enables individuals to record their preferences regarding medical treatment, including end-of-life care, if they lose decision-making capacity. Under Indian legal provisions, the directive must be voluntary, precise, and signed in the presence of two witnesses, along with countersignature by a notary public or attested by a gazetted officer. It can be updated or revoked anytime, provided the individual remains competent.

The sample AMD template from Vidhi Centre for Legal Policy includes sections such as personal details of the individual, specific instructions for treatment (e.g., refusal of life-sustaining treatments such as ventilator support or cardiopulmonary resuscitation), appointment of a healthcare proxy, and declaration and authentication process with signatures of witnesses and the notary public or gazetted officer.¹⁶

This structured format ensures clarity, legal validity, and adherence to the individual's values and preferences in medical care. These directives are voluntary and can be updated or revoked at any time.

Step 4: Documentation of the Binding Refusals

Binding refusals refer to specific treatments a person explicitly chooses to decline under certain conditions, as documented in their AMDs. In the Indian context, as per the guidelines set forth by the Supreme Court, these refusals are legally binding on healthcare providers and surrogate decision-makers, provided the AMD is valid, genuine, and authentic. However, the binding refusal is not absolute; it is subject to reconsideration through the shared decision-making process. A binding refusal may include the rejection of life-sustaining interventions such as cardiopulmonary resuscitation, mechanical ventilation, or dialysis in cases of terminal illness or irreversible conditions.¹⁷

To ensure enforceability, the AMDs must clearly outline the treatments refused and the circumstances in which these refusals apply. The document should be signed by the individual in the presence of two witnesses and attested by a notary or gazetted officer.¹⁷ While surrogate decision-makers must honor these refusals, clinicians may override them if they are deemed inapplicable or have significant uncertainty regarding their interpretation.¹⁸ This framework protects patient autonomy while maintaining flexibility for unforeseen medical scenarios.

Step 5: Witnessing the Living Will

Two impartial individuals must witness a living will, or AMD, to ensure its authenticity and validity. These witnesses cannot be related to the executor by blood, marriage, or adoption and must not have any vested interest in the directive. Additionally, healthcare professionals involved in the patient's treatment, such as the attending physician or treating team members, cannot serve as witnesses.

Step 6: Registration of the Living Will

Registering a living will, or AMD, ensures its legal validity and clarity during implementation. When it comes to voluntary decisions, there is no procedural complexity. For individuals with decision-making capacity, the AMD must be signed in the presence of two impartial witnesses and either notarized by a notary public or attested by a gazetted officer. This simplified process, introduced in 2023, replaces the earlier requirement of judicial magistrate approval, making it more accessible. Additionally, individuals are encouraged to deposit a copy of the AMD with a designated custodian, such as a healthcare institution or local government office, to facilitate easy verification when needed.

For individuals without decision-making capacity, the process involves consultation with surrogate decision-makers and hospital medical boards, as outlined in the legal framework. The appointed surrogate must ensure that decisions align with the individual's documented preferences or, in the absence of an AMD, act in the patient's best interest. The process for withholding or withdrawing life-sustaining treatments in such cases requires the involvement of the medical boards to ensure ethical and legally compliant decision-making. A notary public or a gazetted officer must also attest to the document to further reinforce its legal standing. This process ensures that the living will is unbiased and represents the free and informed consent of the individual.

Step 7: Disseminating the Living Will

Once living is executed, it must be shared with relevant healthcare providers and included in the individual's medical records to ensure accessibility during critical decision-making. A copy should also be provided to the appointed surrogate decision-makers and family members (if desired) and stored securely with a designated custodian, such as a healthcare institution or local authority. While ensuring proper dissemination, strict measures must be taken to maintain the privacy and confidentiality of the individual's directives.

Step 8: Periodic Review and Modification of the Living Will

A living will should be reviewed every 1–3 years or sooner if significant life events occur, such as changes in health, relationships, or living arrangements (e.g., a move, diagnosis of a serious illness, or divorce). Regular reviews ensure the document aligns with the individual's preferences and circumstances. Any updates or modifications must be documented, signed, and attested following legal requirements. Additionally, these changes should be promptly shared with all relevant parties, including healthcare providers, surrogate decision-makers, and document custodians, to avoid ambiguity during implementation.

Step 9: Identification of the Situations Needing Implementation of Living Will

Implementing a living will, or AMD occurs when a patient with a chronic or life-limiting condition experiences significant disease progression and meets specific criteria outlined in the Supreme Court's 2023 guidelines. This includes patients who are terminally ill, have lost the capacity to make or communicate healthcare decisions and require a shift in treatment focus toward comfort, symptom management, quality of life, and dignity rather than aggressive or life-sustaining interventions that are deemed potentially inappropriate or have no clinical benefit.

Step 10: Determination of the Person's Capacity to Make Healthcare-related Decisions

Assessing decision-making capacity is essential to determine whether a patient can make informed medical decisions, including implementing a living will or AMD. The evaluation focuses on four abilities: understanding the medical information, appreciating its relevance to their condition, reasoning through risks and benefits, and expressing a consistent choice.¹⁹ A face-to-face assessment using open-ended questions is conducted, and for patients with cognitive or psychiatric impairments, additional evaluations or consultations with specialists may be required. Capacity is decision-specific and context-dependent, meaning it may vary across different decisions. In India, this process aligns with Supreme Court guidelines, requiring thorough documentation of findings. If capacity is lacking, care decisions must adhere to the AMD or involve the appointed surrogate decision-maker, ensuring alignment with the patient's documented preferences.

Step 11: Review of the Living Will by the Medical Boards

The 2023 Supreme Court guidelines outline the following steps for implementation:

• Verification of AMD validity and applicability: The treating physician must confirm that the AMD is valid, authentic, and applicable to the patient's medical condition. The directive must have been properly executed, with attestation by two impartial witnesses and a notary public or gazetted officer. The physician must also confirm that the patient cannot express their choices.

• Constitution of the primary medical board (PMB): The hospital constitutes a PMB to independently review whether withholding or withdrawing life-sustaining treatment (LST) aligns with the patient's documented wishes. The PMB includes the treating physician and two subject experts with at least 5 years of experience. The PMB must complete its review and provide a recommendation within 48 hours.

• Communication with family or surrogates: The treating team must inform the patient's next of kin, guardian, or surrogate decision-makers (as mentioned in the AMD). They should ensure that these individuals understand the patient's condition, the rationale for implementing the AMD, and the PMB's recommendation. This step seeks consensus and addresses any concerns.

• Secondary medical board (SMB) Review: A secondary medical board is recommended for all cases of treatment limitation for the patient who has lost capacity or if there is disagreement among family members, surrogate decision-makers, or the treating team. The SMB includes one registered medical practitioner, the chief medical officer staff, and two independent subject experts with at least five years of experience who are not part of the PMB. The SMB must review the case and provide its opinion within 48 hours. If disagreements arise during this process, such as between the PMB and the SMB, the case can be escalated to the High Court for resolution.

• Final decision and notification: If the SMB concurs with the PMB's recommendation, the hospital records the decision and notifies the Judicial Magistrate First Class (JMFC) as required by law (Fig. 1).

Fig. 1.

Summary of the Supreme Court of India's legal guidelines for decisions to forgo life-sustaining treatment. Adapted from Mani RK, Simha S, Gursahani R. Simplified Legal Procedure for End-of-life Decisions in India: A New Dawn in the Care of the Dying? Indian J Crit Care Med. 2023 May;27(5):374–376. DOI: 10.5005/jp-journals-I0071-24464. PMID: 37214121; PMCID: PMC10196646

Step 12: Implementation of the Living Will

Implementing the living will, or AMD, involves respecting and adhering to the patient's documented preferences. Healthcare interventions explicitly refused in the living will not be provided, while symptom control, supportive care, and comfort should be prioritized. The treating team implements the AMD by withholding or withdrawing LST following the patient's wishes.

The healthcare team must ensure comprehensive palliative care throughout implementation to alleviate suffering and uphold the patient's dignity. This includes addressing the patient's physical, psychological, social, emotional, and spiritual needs. Family members, caregivers, and surrogate decision-makers should also receive support during this transition, including bereavement support after the patient's death. Open and effective communication between surrogate decision-makers, family members, and the healthcare team is essential to reduce fear, confusion, and guilt, facilitate decision-making, and minimize conflicts over the patient's care.

Cultural and religious considerations must also be respected while implementing the living will. This framework, aligned with the Supreme Court's 2023 guidelines, ensures that AMDs are applied transparently, ethically, and compassionately, prioritizing the patient's autonomy and dignity while fostering a supportive environment.

Implementation, Dissemination, and Review Strategy for the ACP Pathway

Implementation Strategy

• Patients and families: Develop educational tools (pamphlets, videos, guidebooks) addressing key topics like palliative care, stopping treatment, and healthcare surrogates.

• Healthcare providers and institutions: Train providers on ACP, documentation, and execution. Hospitals and insurers will integrate processes for living will implementation.

• Organizations and government: Establish institution-wide policies, designate implementation leaders, create alert systems, and provide a supportive legal framework.

Dissemination Strategy

Make the living will document accessible as an e-book on the ICMR website, publish it in a peer-reviewed journal, and distribute printed copies to key stakeholders, including medical institutes, government bodies, legal firms, and courts.

Review Strategy

Update the living will document every 3 years to reflect changes in technology, law, and public perception. Conduct audits and qualitative studies to monitor implementation, impact, and user experiences.

This approach ensures effective implementation, broad dissemination, and continuous improvement of ACP practices in India.

Discussion

Advanced care planning is essential for ensuring patient care aligns with individual preferences, particularly during declining health. Practical ACP discussions should be patient-driven, focusing on anticipated health changes and guided by the patient's values. Clear documentation of preferences and the appointment of surrogate decision-makers are vital to upholding patient autonomy. The origins of living wills and AMDs trace back to the 1970s, emerging from debates within the Euthanasia Society of America. Human rights advocate Luis Kutner conceptualized living wills as tools to align treatment decisions with patient consent.²⁰ California enacted the first living will legislation in 1976, setting a precedent for integrating end-of-life preferences into legal frameworks. Over time, ACP evolved globally, emphasizing ongoing communication with families and physicians over a sole focus on legal directives.²¹ The United States, for instance, now integrates AMDs with tools like healthcare power of attorney and physicians’ orders for life-sustaining treatment (POLST).²¹ At the same time, European countries exhibit variability in approaches, with some favoring physician-assisted dying over formalized AMDs.²²

Enhancing ACP in India through a 12-step pathway represents a transformative approach to improving patient-centered care, particularly in a culturally diverse and resource-constrained setting. Like other low- and middle-income countries (LMICs), India faces significant barriers to ACP implementation, including cultural reluctance to discuss end-of-life care, family-centric decision-making, and limited awareness among patients and providers.²³ These challenges are compounded by healthcare disparities and a lack of infrastructure in rural areas, where most of the population resides. Despite these challenges, India has taken progressive steps, such as the Supreme Court's recognition of advance directives in 2018, though operationalizing these legal provisions remains limited. A structured pathway could build on this foundation by addressing awareness gaps, fostering community engagement, and tailoring ACP practices to align with cultural norms. Compared to LMICs in Africa and Asia, where community-based palliative care models have facilitated ACP, India can adopt similar approaches, leveraging trusted community health workers and local leaders to normalize discussions and overcome cultural barriers.^24,25 At the same time, lessons from High-Income Countries (HICs) such as the U.S., Canada, and Australia highlight the importance of integrating ACP into routine healthcare through legal instruments, structured training, and public awareness campaigns.²⁶ Unlike HICs with well-established frameworks, LMICs often rely on pilot programs, as seen in Iran and Lebanon, where limited resources have necessitated creative, community-driven solutions.^27,28 In India, a 12-step pathway could address these disparities by embedding ACP into clinical practice and public health initiatives, focusing on capacity building for healthcare providers and scalable delivery models such as telemedicine. Training healthcare providers, a cornerstone in HICs, could be adapted to Indian contexts by developing culturally sensitive communication strategies and empowering providers to initiate ACP discussions effectively. Furthermore, it is crucial to generate evidence to monitor and refine interventions; India could emulate evidence-based approaches like the U.S. POLST program while tailoring them to resource constraints and population needs.²⁹ Community engagement, a proven strategy in both LMICs and HICs, will be critical in India to build trust and promote awareness, particularly in rural areas with low health literacy. By prioritizing localized solutions, such as involving religious leaders and integrating ACP into existing health systems, India can ensure that the pathway is effective and culturally acceptable. The 12-step framework must also strengthen legal and policy frameworks to provide clarity for patients and healthcare providers alike, ensuring that ACP discussions lead to actionable outcomes. Ultimately, the success of this initiative will depend on its ability to bridge the gap between urban and rural healthcare settings, address systemic inequities, and create a model that can serve as a benchmark for other LMICs. By combining lessons from HICs with innovations from LMICs, India's pathway can normalize ACP, improve the quality of end-of-life care, and set a global precedent for implementing patient-centered care in complex healthcare environments.

This work has several limitations, including the involvement of a small expert group, which highlights the need for broader stakeholder engagement to validate the findings. Additionally, there is a lack of real-world implementation data, making it essential to conduct pilot studies to evaluate the feasibility of the framework. There are also challenges in operationalizing the framework, such as institutional resistance and the varying healthcare infrastructure between urban and rural areas.

Future Directions

To enhance ACP, efforts should prioritize improving legal literacy and addressing misconceptions through public education campaigns that present ACP as a proactive and empowering process. It is crucial to increase access to legal and medical resources, especially in underserved areas, and to train healthcare providers in culturally sensitive communication and documentation. Future frameworks should focus on integrating ACP into routine healthcare practices, addressing fears, and providing adaptable solutions suited to diverse cultural and resource settings. Conducting regular policy reviews will ensure that ACP remains relevant, accessible, and aligned with evolving medical and societal needs. Additionally, implementation audits are necessary to track the real-world effectiveness of the framework. There should also be qualitative and quantitative research on the adoption of AMDs across different demographics. Policy advocacy strategies are essential to ensure the seamless integration of ACP into India's healthcare and legal frameworks. Community-based interventions, including public awareness campaigns and the incorporation of ACP into medical curricula, are vital for promoting understanding and acceptance.

Conclusion

Advance care planning and AMDs are essential components of healthcare that involve comprehensive guidance and up-to-date information for healthcare providers, individuals, families, caregivers, and the public. The proposed twelve-step pathway provides an algorithmic approach to ACP and AMDs in India. This framework offers a structured method for implementing ACP and AMDs, ensuring that end-of-life care is ethical, patient-centered, and legally sound. While the streamlined legal procedures introduced in 2023 enhance accessibility, further research is needed to promote wider adoption of these practices and to evaluate the effectiveness of AMD implementation across diverse healthcare settings.

Ethics Approval

CTRI registration or Ethics approval and the need for consent to participate in this study were deemed unnecessary as no patient participated. This is according to guidelines by the Indian Council of Medical Research. Handbook on National Ethical Guidelines for Biomedical and Health Research Involving Human Participants. (Mathur R, ed.). Indian Council of Medical Research; 2018. Available on https://www.icmr.gov.in/icmrobject/uploads/Guidelines/1724914217_handbook_on_icmr_ethical_guidelines_2018.pdf

Authors’ Contributions

Anuja Damani: Writing—review and editing, project administration; Arun Ghoshal: Writing—review and editing, project administration; Krithika Rao: Writing—review and editing; Shreya Nair: review and editing; Roop Gursahani: Conceptualization, methodology, resources; Srinagesh Simha: Conceptualization, methodology, resources; RK Mani: Conceptualization, methodology, resources; Naveen Salins: Conceptualization, methodology, resources, writing—original draft, supervision.

Orcid

Anuja Damani https://orcid.org/0000-0002-4469-0846

Arun Ghoshal https://orcid.org/0000-0001-9975-2568

Krithika Rao https://orcid.org/0000-0002-7679-4850

Shreya Nair https://orcid.org/0009-0008-0844-3558

Roop Gursahani https://orcid.org/0000-0002-6092-1595

Srinagesh Simha https://orcid.org/0000-0003-1560-0079

Raj Kumar Mani https://orcid.org/0000-0003-4759-8233

Naveen Salins https://orcid.org/0000-0001-5237-9874