An informed consent is undoubtedly necessary when withdrawing life support
in a brain dead patients. However, legality and ethics of an informed
consent in such cases is controversial. Parents/guardians need to be
explained the grave prognosis of condition of their brain dead child on
life supporting measures. The existing guidelines for withdrawal and
withholding of treatment in brain dead children are complex. Indian laws
pertaining to treatment of terminally ill patients are dealt under section
14, 21 of Indian constitution and section 76, 81, 88, 306 and 309 of
Indian Penal Code.
The law commission of India laid down an act for the
medical treatment of terminally ill patients (protection of patients,
medical practitioners) [1]. According to this law, if a 'competent'
patient who is afflicted by 'terminal illness' refuses treatment after
being duly informed about all aspects of the disease and treatment, the
doctor is bound to obey the same and withhold or withdraw treatment.
However, when the patient is 'incompetent' (includes minor, person of
unsound mind) and is unable to take decisions for end of life, the doctor
has to take a decision in the 'best interests' of the patient based upon
an informed body of medical opinion of experts. The law might not apply in
situations where the parents/guardians insist on continuation of life
support measures despite being explained the inevitable outcome of the
same.
A recent judgment by the Supreme Court of India has
legalised the withdrawal of life support measures in patients in
persistent vegetative state [2]. Such a decision to discontinue life
supporting measures can be taken by parents, spouse or doctors attending
patient in the 'best interest' of the patient. However, it requires an
approval from high court, which can grant the permission for withdrawal of
life support measures to an incompetent person. The court appoints a panel
of three expert doctors to seek its medical opinion, preferentially one
neurologist, one psychiatrist, and an other physician.
Method for withdrawal of life support measures in such
cases are not clearly defined in law. It might be difficult for the care
giving doctors and staff to pull the brain dead child suddenly out of
ventilator, especially when they have been taking care of the child. Few
methods suggested by experts include ‘Do not resuscitate order’,
withholding use of new medications and slow de-escalation of treatment [3,
4].
References
1. Rao JM. Law commission of India. 196th report on
medical treatment to terminally ill patients (protection of patients and
medical practioners) March 2006. Available from URL:
www.lawcommissionofindia.nic.in/reports/rep196. pdf. Accessed on December
26, 2010.
2. Reportable item no. 1A, Court no.6, Section X.
Supreme Court of India, writ petition no. 115 of 2009, Aruna Ramchandra
Shanbaug Vs Union of India. Available from URL:
www.supremecourtofindia.nic.in/outtoday/ wr1152009.pdf. Accessed on March
17, 2011.
3. Guglani L, Lodha R. Attitude towards end of life
issues amongst pediatricians in a tertiary hospital in a developing
country. J Trop Pediatr. 2008;54:261-4.
4. Balakrishnan S, Mani RK. The constitutional and
legal provisions in Indian law for limiting life support. Indian J Crit
Care Med. 2005;9:108-14.