Author Response: From Courtroom to Intensive Care Unit: The Unfinished Journey of End-of-life Care in India

Thank you, Dr Salhotra, for the thoughtful letter.¹ The end-of-life care (EOLC) journey, though unfinished, appears to have at last found its direction. The evolution of laws to enable withdrawal and withholding of life support has been slow but purposeful in India- from Aruna Shanbaug through the two common cause judgements to the recent Harish Rana case. The clinical and ethical guidelines for EOLC from the Indian Society of Critical Care Medicine (ISCCM) have existed since 2005, but their implementation was poor. This is reflected in the prevalence of terminal discharges as “left against medical advice” (LAMA), only growing in the 8 years between INDICAPS I & II point prevalence studies.^2–4 This was largely because of the intensivist's apprehensions regarding the legal standing of these decisions, which persist to this day.⁵ Through the above judgements, it is now well established in principle that withdrawal and withholding decisions are legally valid and a patient's refusal of life support is a fundamental right. In the Harish Rana case, it was established with clarity that clinically assisted nutrition and hydration (CANH) is in the ambit of medical treatment, not basic, mandatory care, and so can be withdrawn.

Whether an Advance Medical Directive is in place or not, the procedure prescribed by the Court directs a shared decision-making model with the healthcare proxy/family. This is in the patient's best interests as autonomy is combined with the physician's duties of Beneficence and Nonmaleficence. Even the simplified two-step procedure remains cumbersome, but it ensures safeguards for the patient and physicians. As the practice gains traction on the ground, further simplification of the procedure is the way forward. However, the law is only one of several elements in end-of-life decision-making. The latter is driven by clinical judgement and prognostication, assessment of appropriateness of life support, and compassionate care. A 10-step process of decision-making integrating the clinical, ethical, and legal aspects is outlined in the latest ISCCM-IAPC consensus position statement on EOLC and palliative care.⁶ The true safeguards for the physician are skilful communication and shared decision-making with the family, accurate documentation, and effective palliative care. The position statement is the standard of care for EOLC as established by the professional bodies.

Since the concept of foregoing life support still has cultural and psychological barriers, practical implementation is still hampered. We often forget that appropriate care is a clinical and ethical imperative in modern-day critical care practice. We need not wait for all elements of the procedural structure to be put in place by the state government before implementing these decisions. We can be true to the spirit of the judgments and follow the procedural details so far as is possible. The primary board is composed of the treating team of specialists, and a standing secondary board can be put in place in the hospital. As per the Karnataka government order, a member of the brain death committee can function as the District Health Officer appointee in the secondary board.

The glass is half-empty, yet it is also half-full since at long last the dying patient's needs in the ICU are receiving due attention. Intensivists must take the lead in this EOLC movement by shedding hesitation and undue legal worries, focusing on clinical integrity, accurate documentation, and compassionate care.

Orcid

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