Neurologist Roop Gursahani bristles at the phrase “passive euthanasia” to describe the withdrawal of nutrition and water delivered through a feeding tube to 32-year-old Harish Rana, who has been in a persistent vegetative state for over 12 years.
Doctors at the All India Institute of Medical Sciences, New Delhi, are set to initiate a palliative, end-of-life care protocol, replacing the feeding tubes with medications to ease distress and manage symptoms while preserving the patient’s dignity.
The Supreme Court, earlier this month, approved a plea from Rana’s parents to allow the withdrawal of the artificial feeding that has kept him alive since he suffered an irreversible brain injury in a fall in August 2013, when he was an engineering student.
Gursahani and other critical care specialists hope the Supreme Court’s decision —reversing earlier rulings by both Delhi High Court and the apex court itself — will help sharpen public understanding of this complex ethical issue.
“The protocol should be viewed as withdrawal of life support — not passive euthanasia, because euthanasia remains a deeply stigmatised, misunderstood term,” said Gursahani, a neurologist at Hinduja Hospital in Mumbai and
former member of a national task force on end-of-life care.
Gursahani said the supervised withdrawal of artificial feeding should be seen as no different from discontinuing ventilator support, intravenous fluids or medications, or issuing a do-not-resuscitate directive after cardiac arrest.
Such actions fall under what specialists classify as “treatment limitation” decisions, in which patients or their next of kin determine that continuing a specific line of treatment is no longer in the patient’s best interest.
“Some 90 per cent of deaths in intensive care units in the West typically occur under such treatment limitation decisions,” said Raj Kumar Mani, a pulmonologist in New Delhi and former president of the Indian Society of Critical Care Medicine.
The Supreme Court first laid down guidelines for withdrawal of life support in 2011, in response to a petition relating to Aruna Shanbaug, a nurse in a Mumbai hospital who had remained in a vegetative state for decades. The court recognised the right to die with dignity as a fundamental right in 2018 and simplified procedures in a subsequent ruling in 2023.
Yet when Rana’s parents approached Delhi High Court and the Supreme Court in 2024, their pleas were turned down — a reflection, Mani said, of how deeply the issue remained misunderstood.
“That reflected a view that conflated withdrawal of clinically assisted nutrition and hydration with active euthanasia,” Mani said. “Rana’s case unfortunately dragged on for an extra two years because of a widespread misreading that the withdrawal of feeding would amount to euthanasia.”
But in its March 11 verdict, the apex court cited earlier rulings and comparable cases in other countries, and clarified that artificial feeding constitutes medical treatment. It also acknowledged that continuing such intervention in this case was no longer in the patient’s best interests.
The court recommended that AIIMS ensure the withdrawal of artificial feeding is carried out through a palliative care plan designed to manage any symptoms without causing discomfort, while preserving the patient’s dignity.
Experts familiar with palliative care settings, citing similar protocols adopted in the UK, say the end-of-life care programme following the withdrawal of artificial feeding will likely involve the infusion of two key medications: midazolam and morphine.
Midazolam acts on the brain to produce sedation and reduce anxiety or agitation, while morphine helps relieve pain and ease breathlessness by dampening the body’s pain and respiratory distress pathways.
Sometimes, doctors also add drugs known as glycopyrronium to ease breathing and cyclizine to prevent nausea or vomiting.
A patient might die within minutes to hours after withdrawal of a ventilator, depending on the underlying condition, critical care specialists say. “But the process may take a week or even two after the withdrawal of artificial feeding,” an expert not associated with Rana’s treatment said.
Similar cases abroad suggest a gradual and closely managed course. A 2017 paper in the Journal of Medical Ethics described a patient in the UK who died “peacefully” 10 days after artificial feeding was withdrawn, following more than two years in a vegetative state.
In Rana’s case, multiple medical boards had concluded that recovery was unlikely and that continued artificial feeding was prolonging suffering. The court acknowledged his parents’ long vigil, describing it as an act of enduring love, and said that allowing their son to die with dignity reflected compassion rather than surrender.