Can life support be withdrawn if patient is brain dead or has very poor prognosis? Centre releases draft guidelines, invites comments

New Delhi: The Union Health Ministry has released draft guidelines for withdrawing life support from terminally ill patients. These guidelines emphasize that decisions should be made carefully by doctors, considering the patient's medical conditions and overall health status.

The draft guidelines released for public comment state that life support can be withdrawn if a patient is brain dead or if their prognosis indicates they are unlikely to benefit from aggressive treatment.

Stakeholders have been invited to submit their suggestions on the draft guidelines by October 20.

According to an ANI report, the draft states, "A considered decision in a patient's best interests, to stop or discontinue ongoing life support in a terminally ill disease that is no longer likely to benefit the patient or is likely to harm in terms of causing suffering and loss of dignity."

According to the draft guidelines, the withdrawal of life support includes four conditions: the individual must be declared brainstem dead as per the THOA Act; medical prognostication must indicate that the patient's condition is advanced and unlikely to benefit from aggressive therapeutic interventions; the patient or surrogate must document an informed refusal, following prognostic awareness, to continue life support; and there must be compliance with procedures prescribed by the Supreme Court.

"A considered decision in a patient's best interests, to not start a life supporting measure in a terminally ill patient, that is unlikely to benefit the patient and is likely to harm in terms of suffering and loss of dignity," as per the draft.

It explains further that in such a situation, three conditions on whether the individual has been declared brainstem dead, if there is a medical prognostication and considered opinion that the patient's disease condition is advanced, individual declared brainstem death as per the Transplantation of Human Organs Act (THOA), 1994, and patient/surrogate documented informed refusal, following prognostic awareness, to continue life support, have been mentioned in the draft, news agency ANI reported.

The Union Ministry has invited feedback and suggestions by the mid of next month.

On drafted guidelines Dr Asokan, President, IMA, said, "It is actually passing stress to the doctors, all these things are done day to day basis, they are already being done by the clinicians. This responsibility is shared between the patient, relatives and doctors in every single case, and the medical profession has been doing this responsibility, yes, but this differs from case to case, it is always based on trust, and communication with the patient relatives because actually the decision is made by the Patient relatives. Doctors only enable them by sharing scientific information, clinical situations and other things. Dr Asokan said after studying the documents, we will submit our views."

"ICU care is necessary in many instances where patients have life-threatening conditions. This could range from heart attack, stroke, liver failure, road trauma, pneumonia or snakebite. The presence of expert doctors, staff and life support equipment make the ICU a place where even severely ill patients can recover. That being said, there is a point beyond which such support measures do not make a difference, for instance, in some patients with terminal cancer or advanced dementia in a bedridden person.

These measures are not only expensive but also in limited supply and therefore must be reserved for those who will benefit the most. Guidelines to withhold or withdraw aggressive treatment measures are helpful for both doctors and patients' families while facing difficult decisions." said Dr Rajeev Jayadevan, Pat President, IMA Coachin.

There are things that should be left for being sorted out between relatives, patients, and doctors based on science and situation, Dr Asokan said.

The Terminal illness in the draft guidelines has been defined as 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.

The draft guidelines for withdrawal of terminal illness care include the following criteria: a) Any individual declared brainstem death as per THOA Act. b) Medical prognostication and considered opinion that patient's disease condition is advanced and not likely to benefit from aggressive therapeutic interventions c) Patient/surrogate documented informed refusal, following prognostic awareness, to continue life support; d) Compliance with procedure prescribed by the honourable Supreme Court.

The guidelines also address Do-Not-Attempt-Resuscitation (DNAR) decisions, stating that a considered decision not to perform cardiopulmonary resuscitation (CPR) may be made if there is no realistic chance of survival or meaningful recovery, adds ANI.

The draft stated that the legal principles outlined by the Supreme Court state an adult patient capable of taking healthcare decisions may refuse LST even if it results in death, LST may be withheld or withdrawn lawfully under certain conditions from persons who no longer retain decision-making capacity, based on the fundamental right to Autonomy, Privacy and Dignity, Advance Medical Directives (AMD) that meets specified requirements is a legally valid document.

The guidelines also state that for a patient without capacity, Foregoing of Life Support FLST proposals should be made by consensus among a group of at least 3 physicians who form the Primary Medical Board (PMB).

The PMB must explain the illness, the medical treatment available, alternative forms of treatment, and the consequences of remaining treated and untreated to fully inform the surrogate 6. A Secondary Medical Board (SMB) of 3 physicians with one appointee by the Chief Medical Officer (CMO) of the district must validate the decision by the PMB.

"Active Euthanasia is not lawful," it said.

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