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Life-or-death guide - Norms proposed to stop futile treatment

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By G.S. MUDUR in Delhi
  • Published 25.11.05

New Delhi, Nov. 25: Farhad Kapadia often knows when a patient has lost the battle.

But the critical care specialist has to operate within a legal vacuum when he is faced with the next ? and the hardest ? question: when to withhold or withdraw futile treatment.

The Indian Society of Critical Care Medicine has now proposed guidelines for limitation of life-support treatment to dying patients. The guidelines specify conditions under which treatment for terminal patients may be withheld or withdrawn through a transparent and documented process. (See chart)

The society, a professional body of senior doctors whose opinion is treated with respect, has sent its guidelines to the law commission for its comments.

“It’s important to understand that withholding or withdrawal of treatment is not euthanasia,” said Kapadia, a critical care specialist at the Hinduja Hospital in Mumbai.

The legal systems in many countries have distinguished between the two. Euthanasia is defined as physician-assisted suicide.

In withdrawal or withholding, the doctor decides not to continue with the treatment. There is no direct intervention to ensure death.

“There is a single reason for withdrawal of treatment ? the futility of treatment,” said Kapadia.

Critical care experts have said that in the long run, India will need to legislate to facilitate withdrawal of treatment.

“Euthanasia is illegal in India, but withholding or withdrawal of treatment is not covered by existing Indian laws,” said Raj Kumar Mani, the president-elect of the society, outlining its guidelines at a national conference on bioethics organised by the Indian Journal of Medical Ethics in Mumbai today.

Critical care specialists have said withdrawal of treatment to terminal patients will facilitate a more humane process of dying, reduce the emotional and financial burden on families, and avoid needless stays in intensive care units, thus allowing more rational distribution of ICU resources.

The cost of intensive care unit stay in the private sector can be anything from Rs 5,000 to Rs 20,000 a day, conference delegates said.

The society has proposed that it should be clearly explained to patients and families “with sensitivity” what is expected to happen when support is withdrawn. The doctors should also provide medication to ensure adequate comfort during the terminal phase.

It said prolonged and futile life support can impose enormous economic strain on patients and families. The guidelines are intended to minimise inappropriate treatment and optimise comfort care for the terminally ill by withdrawing life support.

“In an ICU, there comes a time when doctors know a patient is beyond treatment and can only be helped by care,” Mani said. “That is when the quality management of the dying process should begin,” he said.

Studies in the US and Europe indicate that withholding or withdrawal of life support preceded up to 90 per cent of deaths in critical care units. In contrast, a study by Kapadia covering selected Mumbai hospitals showed that withdrawal of life support preceded only 22 per cent of deaths in ICU.

In the vast majority of cases in India, the prevailing practice appears to be full life support to the very end. “Medical technology today allows us to make dying a prolonged and expensive process or a more comfortable process,” Kapadia said.