Advanced directives, DNAR and the plethora of misunderstanding created by various guidelines/policy statements

Advanced directives (AD’s) have been legalized by the Supreme Court of India, in Common Cause vs Union of India. These are written witnessed legal documents by which patients can give explicit instructions as to the nature and extent of medical intervention to be given in a pre-defined and presupposed situation when they may not be in a position to communicate consent.

Physicians have been demanding legalization of Do Not Attempt Resuscitation (DNAR) from time to time and various associations have put forwards their statements and policy documents for the same. However, the Supreme Court of India while recognizing passive euthanasia as a means of upholding patient autonomy, has remained silent on DNAR. Legally no difference exists between act of commission and act of omission, if acting is a duty.

Causing death of a person by an act, provided the act has hastened death and death would not have occurred in the absence of that act, is same as not helping him. Even with regards to passive euthanasia, the Supreme Court has issued directions that are hard to follow in principle by both the common man and the physicians. There is a need to rationalise the process and make it user friendly.

The present guidelines on passive euthanasia seem to be impracticable and too cumbersome to be effectively adhered to. And, there needs to be a legal clarity on the status of DNAR.