New Delhi, March 8: Families of terminally ill patients may not have to knock on doors of high courts to seek permission to withhold or withdraw life support, doctors said today after a finer reading of the Supreme Court ruling on Aruna Shanbaug.
The Supreme Court had yesterday rejected a plea for the mercy killing of Shanbaug, but prescribed a legal procedure under which relatives of patients in persistent vegetative states — such as Aruna — need to approach high courts to withdraw life support.
The 141-page judgment on Aruna’s right to live contains six lines doctors believe are directly relevant to thousands of people in critical care units across the country suffering from terminal illness.
In a section outlining the law in the Netherlands, the Supreme Court appears to acknowledge that certain actions followed in certain critical care situations are “considered normal medical practice”.
These actions include stopping or not starting medically futile treatment, stopping or not starting a treatment at the patient’s request, and speeding up death as a side effect of treatment necessary for alleviating serious suffering.
“These are directly relevant to day-to-day decision-making when we look after the dying,” said Raj Kumar Mani, past president of the Indian Society of Critical Care Medicine (ISCCM), who had helped develop a set of guidelines for end-of-life care.
ISCCM members believe the Supreme Court’s ruling in Aruna’s case has addressed the specific circumstance of a chronic persistent vegetative stage — a condition much less frequent than terminal illness which doctors encounter routinely in medicine.
“A persistent vegetative state is a chronic but stable condition,” Mani said. Patients in persistent vegetative states — such as Aruna — are not in any imminent danger of dying. They may survive for months or years with appropriate life support measures such as heart lung machines or artificial feeding.
“This is quite a different situation from terminal illness where treatment is known to be futile and will only prolong suffering,” said Jigeeshu Divatia, head of critical care medicine at the Tata Memorial Centre Hospital, Mumbai.
“In such cases, doctors and patients or their families sometimes take a decision not to escalate treatment,” Divatia said.
A senior doctor in a leading northern Indian hospital recalled a recent case in which an elderly male patient with advanced terminal cancer had to be placed on a ventilator. His spouse, a doctor herself, on being informed there was no hope for improvement requested that the patient be removed from the ventilator.
“We followed a process, the hospital ethics committee discussed it, and the ventilator was removed,” the doctor said. “In such cases all we’re doing by withdrawing or withholding the treatment is removing roadblocks towards imminent death,” the doctor said.
The patient died a few hours later.
Patients with advanced cancer, vital organ failure, or irreversible and terminal conditions are among candidates for such withdrawal or withholding of therapy.
Critical care medics have also seen families taking home patients when their funds run out.
“Few patients in India have insurance cover — and critical care can be expensive,” said Sandeep Bhattacharya, head of critical care medicine at the Asian Institute of Medical Sciences in Faridabad.
“Sometimes prolonging life only increases suffering,” said Narendra Rungta, president elect of the ISCCM. “But withholding life support does not mean end of care. Patients continue to receive treatment to ease pain or suffering,” said Rungta, a critical care specialist in Jaipur.