In a landmark move, the Ministry of Health and Family Welfare recently released draft Guidelines for the Withdrawal of Life Support in Terminally Ill Patients. These guidelines aim to operationalise the Supreme Court’s historic judgments from 2018 and 2023 that affirmed the constitutional right of every Indian to die with dignity.
While India still does not have a dedicated law governing the withholding or withdrawal of life-sustaining treatment, the Supreme Court’s rulings and the Ministry’s draft guidelines together form a legal and ethical framework for hospitals and families navigating the complex terrain of end-of-life care.
Legal Backdrop: The Supreme Court’s Orders on end of Life care in individuals who have made a Living Will
The 2018 Common Cause vs. Union of India judgment was a watershed moment. The Supreme Court recognised the right to die with dignity as part of the constitutional right to life under Article 21. The Court also laid out a framework for advance directives or “Living Wills,” and for the withdrawal of life-sustaining treatment in terminally ill patients.
In 2023, the Supreme Court further simplified the process and reiterated the need for operational clarity. The recent draft guidelines issued by the Ministry aim to fulfil that mandate. The Supreme Court gave the following orders for deciding end of life care in terminally ill situations.
Formation of Medical Boards
- Primary Medical Board: Set up at the hospital level, comprising treating physicians and specialists. This board evaluates whether continued life-sustaining treatment is beneficial for the terminally ill patient.
- Secondary Medical Board: Consists of independent doctors nominated by the District Chief Medical Officer (CMO) or equivalent authority. This board reviews and either confirms or rejects the Primary Board’s decision.
This two-tiered structure ensures checks and balances, and safeguards patients’ rights while maintaining medical accountability.
What Is Withholding or Withdrawing Life-Sustaining Treatment?
Withholding or withdrawing life-sustaining treatment refers to the deliberate decision to not initiate or to discontinue medical interventions that prolong life but no longer offer benefit to the patient. These may include:
- Mechanical ventilation (ventilators)
- Artificial nutrition and hydration (feeding tubes)
- Dialysis
- Cardiopulmonary resuscitation (CPR)
- Certain medications or surgeries
The goal in such decisions is not to hasten death, but to avoid prolonging suffering in a situation where treatment is deemed futile and the underlying illness is irreversible. Comfort care, often called palliative care, is continued to ensure the patient is free from distress and pain.
Can End‑of‑Life Care Be Given Without a Living Will?
For individuals who haven’t made a living will, India’s legal and medical landscape still allows for ethical, structured end-of-life decision-making:
- Family or Next Friend Decision-makers: Courts have recognised that in absence of a directive, decisions can be made by close relatives or a nominated next friend, subject to medical review and legal oversight (as in Aruna Shanbaug)
- Medical Boards in Hospitals: The current Supreme Court‑mandated process (reflected in the Ministry’s draft guidelines) permits withdrawal of treatment through a two-tier board system even without a living will—a Primary Medical Board and an independently appointed Secondary Medical Board review and confirm the decision
- Advance Care Planning (ACP) Influence: Even when a formal document is absent, prior conversations about treatment preferences can guide doctors and families to honour the patient’s values and choices during terminal illness or incapacity
- Ethical Guidelines by Professional Bodies: ICU and palliative care protocols issued by medical bodies like ISCCM, IAPC, and ICMR offer structured guidance for DNAR decisions and limitation-of-treatment frameworks when no written directive exists. These are widely used as practical standards in many institutions.
What This Means for Hospitals and Families
The Supreme Court Judgements of 2018 and 2023:
- Clarify that withholding or withdrawing treatment is legally permissible in India when done within the defined framework.
- Provide a clear institutional process to guide healthcare providers and protect them from legal liability, including the Primary and Secondary medical boards
- Empower families and patients to make informed choices about care at the end of life, aligned with their values and preferences.
- Lay the groundwork for respectful, humane, and patient-centric end-of-life care in India.
Even without a living will, India’s current legal landscape now allows structured, legally protected end‑of‑life care decisions. Still, drafting a living will or advance directive remains the best way to ensure one’s wishes are respected clearly and efficiently. Until we have a legislation, these evolving norms offer hope for quality end-of-life care for all Indians.