Dhanada K Mishra
magine that a close relative at the peak of his/her life has been hospitalised with a life-threatening ailment and the doctor has asked you whether or not to place this person on life support. It happens all the time, and this reality is frightening. On one hand such decisions subject relatives to great emotional trauma. On the other, especially in case of poor patients in government hospitals, the decisions are made on the patient’s behalf under dubious circumstances.
In March 2018, a five-member bench of the Supreme Court passed a historic order that allowed Indians to sign a ‘Living Will’, if they chose to not prolong life by artificial means when in a coma. Also known as passive euthanasia, the order allows a person to choose a right to ‘dignity in death’ just as s/he enjoys a right to ‘dignity in life’. This is in contrast to euthanasia that involves voluntarily taking one’s life with the assistance of a third person – often a medical doctor who administers the least painful process of death. Euthanasia is still illegal in India and in most countries all over the world.
The history of living wills dates back to 1969 when the American lawyer Louis Kutner first proposed it. He viewed it as a simple device to allow patients to say no to life-sustaining treatment that they did not want, even if they were too ill to communicate. It is now accepted in most countries, India being one of the late comers to the group.
The Supreme Court verdict of 2018, upheld a 2011 judgement of the court on the same subject that had been initiated by activist-journalist Pinki Virani on the Aruna Shaunbag case. Aruna had been a nurse at the King Edward Memorial Hospital in Mumbai. She survived sexual assault but suffered serious spinal injuries and slipped into a coma. She remained in the vegetative state for 42 years until her death in 2015.
Most people who choose to sign a DNR or ‘living will’ prohibiting the use of resuscitation followed by life support system, do so to avoid possible difficult quality of life after the event. While advising patients and family members on DNR, data on survival rate of as high as 26 per cent when administered in hospital and as low as 10 per cent outside hospitals in 2018 are cited. The risk of physical injury such as rib bone damage (13 per cent), post discharge need for assistance in daily life tasks (5-10 per cent) and mental decline (5-21 per cent) are other factors that people have to consider while signing DNR. While considering all these aspects, the patient and his/her family need expert counselling and advice from experts in medical ethics and other professionals that all hospitals should provide.
Prior to the 2018 verdict, DNR was discussed verbally between patients and doctors. In a 2006 case study reported in the ‘Indian Journal of Medical Ethics’, the decision of providing resuscitation and life support to terminally-ill patients was made out to be mainly dependent on financial situation of family. The Indian Society for Critical Care Medicine (ISCCM) had in place a guideline for interventionists for end-of-life care, including DNR, since 2005. In a survey of 169 critical care physicians conducted in 2015, 55 per cent said they practice DNR unilaterally.
The pros and cons of resuscitation and life support should become part of every consultation before any major treatment ensues, with the patient or designated representative forming an integral part of such consultations. An informed ‘living will’ would make the decision-making process that much easier for the family member signing the consent on behalf of the patient. The process of deciding whether to let a dear one die will never ever be easy, but it will make it easier to let go if you knew that the person would have wanted it and that it was their choice that you eventually enabled.
The writer is an academician currently visiting Hong Kong University of Science and Technology as a Research Scholar. e-Mail: firstname.lastname@example.org.