Indian Council of Medical Research Redefines ‘End of Life Care’

Highlights:

• ICMR redefines end-of-life care protocols in the country
• Recommends informing patient and family about DNAR and CPR and outcomes where applicable
• Confirms that CPR is not a default option in medically futile situations
• Treating physician(s) to decide on performing CPR vs allowing natural death
• Supportive and compassionate care will continue in the event of a DNAR order

The medical professionals of India have finally found an answer to the conundrum surrounding the Do Not Attempt Resuscitation (DNAR) protocols. The BioEthics unit of the Indian Council of Medical Research has made their position on the matter of DNAR orders and Cardiopulmonary resuscitation (CPR) through a paper appearing in the current issue of the Indian Journal of Medical Research. This kick-starts medico-legal based reforms in end of life care in India, alongside the Supreme Court’s judgment of 9 March 2018 (Common Cause vs. Union of India). The judgment stressed that dignified death is a fundamental right and declared that an adult capable of making an informed decision has the right to refuse all forms of medical treatments including withdrawal from life support. This landmark verdict paved way for Physician Assisted Suicide (PAS) or passive euthanasia.

Doctors in India, for the past five decades, have been trained to be confident about always performing CPR when the heart and breathing stop. There is an unwritten supposition that they could come under the legal radar if they fail to perform CPR, even in case of a patient dying from an incurable or terminal disease. However, the current practices related to this matter around the globe, are highly contrasting.

The newly published report on this subject recommends that in cases where CPR would probably be required, the patient or family/surrogates be informed about this and the possible outcomes, thus making it an ideal medical practice. This stand eliminates the numerous uncertainties clouding the subject.

Cardiopulmonary resuscitation (CPR) is the medical technique used to restart the heart and breathing when they cease unexpectedly. It could be lifesaving when performed promptly on a reasonably healthy patient. However, this gives rise to the question of the procedure being unsuccessful if delayed for some reason or performed on someone already critically ill. As a matter of fact, things could take an adverse turn; while the heart may have restarted, as a consequence of loss of blood circulation for a crucial amount of time, the brain could be severely damaged. CPR could be traumatic and unfruitful, result in broken ribs and may also needlessly prolong death, particularly in weak, ailing aged patients.

ICMR has endorsed that CPR is not a default option in end-of-life care situations. Rather, it is only a medical procedure that should not/does not have to be performed in certain circumstances where it only may prolong the suffering of patients with incurable illnesses. It therefore becomes the responsibility of the treating physician(s) to make the final call about DNAR and CPR, based on the ICMR consensus guidelines.

References:

1. Mathur, Roli. ICMR Consensus Guidelines on ‘Do Not Attempt Resuscitation’. Indian J Med Res. Apr 2020;151:303-310.DOI: 10.4103/ijmr.IJMR_395_20
2. Important Judgment of the Supreme Court of India - (https://nhrc.nic.in/press-release/important-judgment-supreme-court-india-1)

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Source-Medindia