Whether to pull the plug or not on a terminally ill patient is often a vexed ethical question for both relatives and physicians. The Indian Council of Medical Research (ICMR) is set to finalise next month the principles that will guide physicians on whether or not to perform Cardiopulmonary Resuscitation (CPR), that is put a patient on a ventilator, if there is an incurable disease where the patient’s chances of survival are extremely low.
The National Consultation meeting on ‘Do Not Attempt Resuscitation’ (DNAR) under the chairmanship of Prof. Balram Bhargava, DG, ICMR, and Secretary, Department of Health Research, is scheduled for December 2.
Speaking to The Indian Express, Dr Bhargava said: “There are many terminally ill patients who know they are not going to make it, their relatives also know that they are not going to make it. The DNAR is just a way for them to exercise the option of not being put on ventilator. Many other countries have DNAR guidelines.”
Currently, this is practised only informally, through a verbal contract between a patient and physician, provided the physician is amenable to the idea. Most hospitals demand a document from the court if a patient makes such a request through official channels.
Many countries allow DNAR orders to be issued. These include the US, UK, Spain, French, Norway and the Netherlands.
According to the American Medical Association, “Orders not to attempt resuscitation (DNAR orders) direct the health care team to withhold resuscitative measures in accord with a patient’s wishes. DNAR orders can be appropriate for any patient medically at risk of cardiopulmonary arrest, regardless of the patient’s age or whether or not the patient is terminally ill. DNAR orders apply in any care setting, in or out of hospital, within the constraints of applicable law.”
The option to refuse life-prolonging interventions was made available to patients when the Supreme Court in March last year allowed a “living will”, that is, it recognised a person’s right to issue advance directive on the course of his/her treatment, including withdrawal of life support, should such a situation arise. However, there are complicated questions of medical ethics involved in a living will. There were so far no guidelines available for doctors on these aspects. The ICMR position paper will thus be the first of its kind.
Some years ago the health ministry had initiated a Bill on this subject. However, the Medical Treatment of Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill has been pending for a long time.
According to the Bioethics Unit of ICMR, “The purpose of the (DNAR) document is to not prolong the suffering of the patient and to preserve the dignity in death by not performing CPR along with compassionate care. The document also highlights that the treating physician should deliver complete information to the patient/surrogate(s) regarding the decision on DNAR. It is expected that this document would help patients/surrogate(s) receive needful information and guide the treating physicians to reach to a decision in the best interest of the patient.”
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