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Procedures to implement the Supreme Court of India directives to withdraw/withhold life-sustaining medical treatment
For correspondence: Prof Nandini Vallath, Department of Pain, Palliative Medicine and Supportive Care, St. John’s National Academy of Health Sciences, Bengaluru 560034, Karnataka, India e-mail: nandini.vallath@stjohns.in
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Received: ,
Accepted: ,
How to cite this article: Vallath N, Parvathy V, Padhi P, Angelin JT, Krishnakumar M, Varghese PS. Procedures to implement the Supreme Court of India directives to withdraw/withhold life-sustaining medical treatment. Indian J Med Res. 2026;163:319-26. doi: 10.25259/IJMR_3005_2025.
Abstract
In 2018, the Supreme Court of India legally recognised the rights of patients with terminal illness through the judgement in Common Cause (A Registered Society) v. Union of India and Another, (2018) 5 SCC 1. The processes prescribed to withhold or withdraw artificial life-support medical treatments became practical after the 2023 amendment. The law aimed to ensure the dignified dying of sick individuals whose condition was deemed terminal and irreversible. Healthcare institutions can comply with the Court’s guidelines in their entirety only after the concerned State Governments activate specific processes. Karnataka state activated the legal mandates by early 2025. Using an implementation case study, we describe the institutional processes to uphold the ethical and legal mandates when withholding/withdrawing life-support treatment (WH/WD-LST) in a mentally incompetent, terminally ill elderly patient, admitted to a tertiary care hospital in Karnataka. It aims to clarify, (i) validation of ‘Advance-Medical-Directive’, or the living will; (ii) sequential institutional processes for WH/WD-LST as per ethical and legal mandates; (iii) constitution of the primary, secondary medical boards (PMB, SMB); (iv) reporting formats for PMB, SMB evaluations, and (v) the templates relevant to institutional administrators to convey the mandated details of WH/WD-LST to their jurisdictional judiciary magistrate of first class. The impressions and impact of activating the living will and WH/WD-LST on the family, on patient care, for the professionals, and for the institution are described in brief.
Keywords
Advance directives
End-of-life-policy
Living wills
Medical futility
Supreme court-judgment
Terminally ill
This implementation case study from a tertiary healthcare setting describes the stepwise procedures to respond to the request for withdrawal (deactivating the defibrillator function of the implantable cardioverter-defibrillator (ICD) and withholding life-support treatments (non-escalation to intensive care facility) by the legal decision-makers on behalf of a terminally ill in-patient with advanced dementia. After a written informed consent from the patient’s legal representative, the study proposal was reviewed and approved by the Institutional Ethics Committee.
Case Vignette
An elderly 83-year-old male, a US citizen with an overseas-citizen-of-India (OCI) card, was hospitalised under the department of Palliative Medicine on September 9, 2025, for management of his agitated delirium, optimising comorbidities, and seeking a continuum of supportive care beyond institutional stay. He had had two acute coronary events in 1988 and in 1993, following which he underwent coronary artery bypass graft surgery. An implantable cardioverter-defibrillator with pacemaker function was placed in 2014 for recurrent unexplained syncopal episodes associated with arrhythmia, as a precautionary measure, as he was also an avid trekker.
In 2019, he developed cardiac failure with progressive cardiomyopathy. His multi-morbidities included long-standing diabetes mellitus, hypertension (both for 50 yr), depression, paranoia, and panic attacks since 1988, along with a gradually progressive neurodegenerative condition with dementia (2016), and stage 4 chronic kidney disease (2021). The couple arrived in India in 2022 for socio-cultural reasons, to be with their extended family. They stayed on in view of his worsening medical condition and to maintain family-connectedness.
As his dementia with delirium deteriorated, his wife and daughter sought the best supportive care. During the inpatient admission, they shared their fear that automated ICD defibrillation could prolong and add suffering to his dying process. They expressed their wish to protect him by deactivating the defibrillator function of his ICD and by withholding artificial life-sustaining medical treatment (WH/WD-LST), including intubation, dialysis, mechanical ventilation, and tube feeding.
Our institution was adequately prepared with mandated procedures: (i) the Karnataka Health-Secretariat had circulated orders (February 2025), to implement the due processes as per the amended Supreme Court judgment,1-8 (ii) there was a State-empanelled brain death declaration committee (BDDC), that fulfilled the legal mandate for forming the two medical boards required as per the Supreme-Court directives (SC-Directives),6 and (iii) it had well-integrated, palliative care services. The hospital administration had also received the official email ID of their jurisdictional judicial magistrate of first Class (JMFC) from the Bengaluru metropolitan magistrate’s office. The transformed legal scenario in the State allowed the institution to proceed with the request for WH/WD-LST, by applying the ethical, legal, and central-state-government mandates, when considering the request for deactivating the defibrillator and withholding other LST for this patient.
Procedural intervention
Table I and Figure briefly depict the stepwise institutional processes for activating the request for withholding/withdrawal of life support medical treatment (WH/WD-LST as per the legal mandates of the land.
| Step 1 |
| The enquiry for WH/WD-LST as a request from the family/caregiver OR in the course of family - clinician discussions |
| Step 2 |
| Checking for/validation of the Advance Medical Directive (Living Will -AMD) by the treating physician |
| Step 3 |
| Signed request and consent from the surrogate for WH/WD quoting reasons and with signatures of witnesses (Supplementary Material 1). |
| Step 4 |
| Discussions between the treating physician and the family. A) Establish irreversibility of the condition; B) Evaluate healthcare decision making capacity; C) Evaluate full comprehension of consequences of the request for WH/WD-LST & D) specific to the patient, e.g., family awareness; ICD interrogation- report |
| Step 5 |
| An official email request from the treating physician to the Chief Administrator of the institution, to activate the institutional procedures processes for WH/WD-LST |
| Step 6 |
| Constitution of the Primary Medical Board (PMB) by the Chief Administrator of the institution including i) the treating physician and two subject experts: all with more than five years of post-qualification clinical experience. |
| Step 7 |
| The PMB evaluates the patient, interacts with family, documents and signs their report in the suggested format (Supplementary Material 2) and submits to the Chief Administrator within 48 h. |
| Step 8 |
| Constitution of the Secondary Medical Board (PMB) by the Chief Administrator of the institution, with a different set of clinicians having more than five years of post-qualification clinical experience; with one empanelled by the State (alternative in Karnataka - empaneled member of the Brain Death Declaration Committee) |
| Step 9 |
| The SMB evaluates the patient, interacts with family, documents and signs their report in the suggested format (Supplementary Material 3), and submits to the Chief Administrator within 48 hours of their formation. |
| Step 10 |
| The Chief Administrator conveys of the PMB, and SMB concurrence reports to the Judicial Magistrate of 1st Class (JMFC) and conveys the following documents to the jurisdictional JMFC: 1) The concurrence reports of PMB and SMB – in the prescribed format; 2) The copy of the AMD OR, the request and consent of the surrogate decision maker, in the prescribed format; and 3) And a cover letter explaining the background circumstances. |
- The sequential institutional processes, including the central legal mandates and Karnataka State processes. This Flowchart depicts the sequential processes required in healthcare institutions in India, to withhold/withdraw life-sustaining medical treatment. It integrates the legal mandates, with the procedures recommended by the central government and prescribed by the State government of Karnataka. WH/WDLST, withholding/withdrawing life sustaining treatment; JMFC, judicial magistrate of first class; AMD, advance medical directive; PMB, primary medical board; SMB, secondary medical board. *When there is non-concurrence between the PMB, SMB reports, the Supreme-court recommends alternative pathways involving the High court and senior subject-experts, from outside the institution.
Step 1. Request from the family/caregiver
Patient’s wife and daughter, both medical professionals, were the legal decision-makers. They shared a living will, recorded earlier by the patient, and requested deactivating the defibrillator function of the ICD.
Step 2. Validation of the advance medical directive (AMD/living-will)
His AMD was recorded and authenticated in 2017, in California, USA, as per the regional mandates. It contained clear instructions not to initiate/escalate futile medical interventions when his health condition became irreversible or terminal. He had expressed his wish to avoid life-support machines if his condition became such that he was unable to talk to family, friends, or wake up from a coma, feed, bathe, or take care of himself, and live without being hooked up to machines. He had named his wife and daughter (both physicians) as his surrogate decision-makers.
Yet, as this living will was not executed according to the SC-Directives, and as per the notification by the Karnataka government with regard to validating advance medical directives4,5,7,8, it was not legally valid. Nevertheless, as the patient held an OCI card and had been residing in India continuously since 2022,9 Indian civil and healthcare laws were applicable and procedures for situations without AMD were followed.
Step 3: Signed request and consent from the surrogate
The patient’s wife submitted a signed request and a witnessed consent form for deactivation of the defibrillator function of the ICD, while preserving the pacemaker function. This was done in the format recommended by the Government of India10 (Supplementary Material 1). The reason quoted was to protect her husband from needless pain and suffering and a prolonged dying process resulting from defibrillator activation during the terminal phase and other life-sustaining treatments.
Step 4. Discussions between the treating physician and the family
Step 4A: Establishing irreversibility of the condition
The treating team evaluated the patient with reference to the ICMR definitions and consensus documents11,12 that helped to standardise, update, and remove ambiguities with regard to terminal illness, withholding/withdrawal, and end-of-life care (EOLC). Despite multi-specialty input from neurology and psychiatry, his multi-morbidities could neither be reversed nor optimised, and his multi-system deterioration was irreversible. His palliative performance scale (PPS) score13 was 30, as he was bedbound, with total dependency for self-care, minimal oral intake, fluctuating consciousness, and delirious episodes, which justified his status as terminally ill.
Step 4B: Evaluating healthcare decision-making capacity
His cognition and orientation to time and person remained poor, despite neuro-psychiatry specialist involvement. He lacked the mental capacity to make an independent, informed decision regarding his own healthcare.
Step 4C: Evaluating comprehension of consequences of WH/WD-LST
The team discussed the pros and cons of continuing with the ICD and the consequences of deactivating the defibrillator function with the primary decision-maker, his wife, herself a medical doctor. The treating team ensured her insight and full comprehension of the consequences of WH/WD-LST.
Step 4D: ICD interrogation report
The team ordered a non-invasive electronic evaluation of the ICD to check its battery life, lead functions, and heart rhythm data, to document the historical dependence of the patient on the device.
Then, the treating physician concurred with the request of the family and proceeded with the mandated institutional steps to activate the WH/WD-LST in the best interest of this patient.
Step 5: Request from the treating physician to the hospital administrator for withdrawal of life-support device
The treating physician then sent an email request to the chief of medical services (CMS) to activate the due processes recommended for WH/WD-LST.5-8,10-12
Step 6: Constitution of the primary medical board
The CMS constituted the primary medical board (PMB), which included the treating physician and two subject experts: one cardiologist and one intensivist, all with more than five years of post-qualification clinical experience.3
Step 7: Evaluation of the clinical situation and submission of report by the PMB
The PMB came together to clinically evaluate the patient in the presence of his wife. The investigations and medications were reviewed, and reversible causes for his poor mental capacity were assessed and excluded. They noted minimal use of pacing and nil usage of defibrillator function in the ICD interrogation report.
The PMB also ensured that the wife comprehended the consequences of deactivating the ICD and confirmed her consent to proceed. They then signed their evaluation report in the format suggested by the Government of India10 (Supplementary Material 2) in support of the family’s request for deactivating the defibrillator and WH other LST and submitted it to the CMS by email and as a hard copy.
Step 8: Constitution of the secondary medical board
The CMS then constituted the secondary medical board (SMB) with a different set of clinicians having more than five years of post-qualification clinical experience.8 One was a neurologist who was also an empaneled member of the BDDC of the State, as required by the legal and government mandates for forming the SMB.6 The other subject experts included a senior intensivist and a senior physician.
Step 9: Evaluation by the SMB and submission of their report
The SMB evaluated the patient, noted the psychiatrist’s opinion, and medications. They administered the Addenbrooke cognitive test14 in which he scored 26/100. Once the irreversibility of his mental condition and lack of decision-making capacity were established, the SMB interviewed his wife and confirmed her comprehension of the consequences of discontinuing the defibrillator, before concurring with the PMB decision. The SMB then signed their evaluation report in the suggested format10 (Supplementary Material 3) and submitted their report to the CMS by email and as a hard copy. They advised continuation of the best supportive treatment for the symptoms and for the underlying medical comorbidities.
Step 10: Conveyance of the PMB and SMB concurrence reports by the CMS to the judicial magistrate of first class (JMFC)
Submission of reports of the PMB and SMB each were achieved within 48 hours of their constitution, as required by the SC-directives. The CMS completed the legal requirements to deactivate the defibrillator function of the ICD and not to escalate the patient’s care to artificial support by conveying the following documents to the official email of the jurisdictional JMFC10 (Supplementary Material 4).
(i) The reports of both the PMB and SMB, that concurred to deactivate the defibrillator function of the ICD– in the prescribed format; (ii) the request and consent of the patient’s wife in the prescribed format; and (iii) a cover letter explaining the background circumstances.
Follow-up and outcomes
The technologist was subsequently summoned to deactivate the defibrillator function. The patient continued as an inpatient for two weeks more, to optimise his care, for educating the personal caregiver, and to optimise his agitation and sleep. He was discharged once symptoms were controlled, medications reconciled, and the family felt confident to manage his care at home. The palliative home care team provided weekly reviews to maintain his care continuum. The patient died pain-free, at home, surrounded by his family, on the 45th morning after deactivating the defibrillator.
Discussion
With the advent of advanced technology to support most vital functions, the processes to identify which patient is critically ill and who is terminally ill have become blurred.15 Medicalised death, with terminally ill patients dying with futile intensive interventions, has resulted in immense emotional and financial hardship for the families, moral distress for the healthcare providers, and a painful death for the patients.16-18
India’s trajectory towards dignified end-of-life care (EOLC) has taken a major leap with the 2023-amendment of the Supreme Court (SC) judgement 2018,1-3 that simplified the processes to evaluate and proceed with WH/WD-LST. The judgment upheld the right to life with dignity of a terminally ill patient and granted legal recognition to Advance-Medical-Directives–AMDs (living Will). The SC-Directives could be activated in Karnataka, only when the State-Health Secretariat filled in the last-mile gaps for implementing the legal procedures (Table II).4-8
| Legal requirement as per the supreme court judgement | Solution by the health secretariat of Karnataka |
|---|---|
| 1. The Custodian (the competent officer) is designated by the local government such as the municipal corporation, municipality, or panchayat. The Custodian is responsible for securely maintaining the Advance Medical Directive AMD-living will document in a registry. |
•AMD custodians in Rural Areas: Executive Officer of the concerned Taluk Panchayath7 •AMD custodians in urban areas: Joint commissioners of BBMP zones for Bengaluru4,8 |
| 2. Physician empanelled by the district Chief Medical Officer is mandatory to form the three-member Secondary Medical Board |
•Clinicians already approved under the Transplantation of Human Organs and Tissues Act (1994, amended 2011) for certifying brain-stem death will be deemed to be nominated by the District Health Officer to serve as a member of the Secondary Medical Board for WLST/AMD cases.6 •Being a multi-specialty medical college hospital, our institution had empanelled members for certification of Brain Death as per the Section 36 of the Transplantation of Human organs and Tissues Act 1994, as amended in 2011.23 The recognition of this set of empanelled members as adequate for the SMB by the Karnataka state health secretariat helped the institution to activate the required legal mandates. |
| 3. The institution administration has to ‘convey’ the concurrence reports of both, the Primary and Secondary Medical Boards and the surrogate request/consent to the Jurisdictional JFMC, before acting upon the decisions. | •The Chief of Medical Services of our institution received the E-mail ID of the Jurisdictional Judicial Magistrate of First Class, in response to an official request for the same, sent to the official E- mail of the Bengaluru Metropolitan Magistrate |
| 4. General awareness of the concerned officials (e.g. Chief District Health Officers, the JMFCs, clinical establishments, government hospitals, local governments, high-court registry, and public information officers), through communication-orders, explaining their roles in executing the Supreme Court mandates. | The respective communications are getting prepared/underway from the State Government offices to the officials and establishments concerned with the implementation of the SC directives viz. the district chief medical officer, clinical establishments, government hospitals, local governments, JMFCs, high-court registry and public information officers. |
As WH/WD-LST is a crucial need, many institutions have developed pathways to support de-escalation of care, even before the SC-directives came into effect. Several studies explaining the advance care-planning and operational procedures for WH/WD-LST have also been published,19,20 since the SC-judgement. Although there are significant variations when making decisions around WH/WD-LST, the legal-ethical processes in India reflect some of the core recommendations being considered across the globe.21,22
This implementation case study is unique in its diligent recording of specifics when adhering to the legal mandates of implementing WH/WD-LST in an institution, including the practical, ethical, and governmental legal nuances, demonstrating feasibility and practicality. What did this implementation mean for the patient-family, the professionals, and the institution?
It prevented the needless suffering of the patient due to a prolonged dying process. The family felt listened to, cared for, and treated beyond the physical domain, towards maintaining the dignity of their loved one.
The two ICMR publications; (i) Definition of terms used in limitation of treatment, and (ii) on Do-Not-Attempt-Resuscitation,11,12, not only clarified those terminologies but also encouraged reflective thinking when making decisions for the irreversibly ill. This helped resolve the hesitation of professionals to engage with terminal-care decision-making.
The decision-responsibility shared with the primary and secondary medical boards brought objectivity and normalised the approach to an otherwise complex situation. The procedures supported clinicians to safeguard their patients’ best interests, alleviate their own ethical-moral distress, while still being within legal boundaries.
Timely WH/WD of inappropriate, non-beneficial, expensive, and burdensome interventions permitted transitions to proportionate care alternatives. For example, it helped transition ‘discharge aginst medical advice’ (DAMA) situations, to palliative home-based-end-of-life care. It prevented suffering of the patient, reduced the angst of the family,16-18 avoided moral distress of clinicians, while averting catastrophic healthcare expenses.18
The streamlined processes have since enabled identification of futility, WH/WD-LST decisions, and care transitions at other settings, including neonatal and paediatric ICUs and inpatient settings.
Acknowledging the essentiality of WH/WD-LST, the administration of our institution has launched workshops for post-graduates and faculty on the ethical and legal pathways to end-of-life decisions for terminally ill patients.
The stepwise processes of ethical, medical reasoning to determine futility/burden of procedural interventions described here, and the templates shared for recording living will (AMD), PMB, SMB reports, the surrogate request/consent, and for communicating to the JMFC (Supplementary Materials 1-5), can assist other institutions with BDDC, to activate WH/WD–LST.
One foreseeable barrier would be at the prognostication level of PMB/SMB, which needs to differentiate a critically ill person from one who is terminally, irreversibly ill. Clinicians may find it difficult to diverge from conventional practices focusing on organ functions, the ‘effect’ of the LST on parameters (blood-pressure, partial-pressure of oxygen (PaO2), or creatinine), to discern the overall ‘beneficence’ to the whole person. The nuanced legal procedures may stimulate deeper, mature, reflective, and ethical enquiries to clarify what will best serve in the ‘best interest’ of that patient-person.
The steps required at the state-level, for implementing SC-Directives on the living will, are at four levels, and Table II indicates the implementation steps required at the state-levels and lists the developments at the Karnataka state-health-secretariat. Besides what is operationalised, there are certain state-level actions required before the WH/WD-LST pathway can be utilised by all institutions. The state has yet to officially communicate the legal mandates, SOPs, and templates to make its healthcare institutions aware of the recent developments. District medical officers need official orders explaining their role for empanelling the SMB members, without which healthcare institutions that do not have the ‘brain death declaration committee’ cannot activate WH/WD-LST.23 The SC-mandated procedures for resolving decision-conflict-situations, (i) between the family and treating physician, or (ii) non-concurrence of PMB and SMB reports, require actions involving the high court. The stakeholders at the state department, the JMFCs, and the judiciaries including the Registrar (High Court), need official communications from state authorities on their roles/duties in connection with the AMDs and WH/WD-LST.
India consistently ranks low on the quality of death index, at 67th out of 80 countries in 2015 and 59th out of 81 in a 2021 review.24,25 As described through this case vignette, adhering to the prescribed legal, ethical mandates can help improve the quality of death of individuals and transition an isolated, sterile, painful, expensive15-18 and undignified death with intensive care, to caring intensively at their preferred place, surrounded by their loved ones.
Acknowledgment
The authors acknowledge Smt. Uma Mahadevan, IAS, and Sri. Harsh Gupta, IAS, for their leadership in paving the last mile to operationalise the Court directives in the State of Karnataka. Authors also acknowledge the contribution of Vidhi Centre for Legal Policy, which has done pioneering work to ensure that the legal reforms are applicable on the ground. The authors further express their deep gratitude to the family of the patient, who encouraged the publication of this implementation study to help clarify the prevailing ambiguity and ensure clarity around activating SC-legal mandates for the terminally ill in India.
Author contributions
NV: Concepts, design, definition of intellectual content, literature search, data acquisition, manuscript writing; PV: Concepts, design, definition of intellectual content, literature search, data acquisition, manuscript writing; PP: Literature search, data acquisition, manuscript writing; AJT: Literature search, data acquisition, manuscript writing; MK: Concepts, design, manuscript writing; VPS: Definition of intellectual content, manuscript writing. All authors have read and approved the final printed version of the manuscript.
Financial support and sponsorship
None.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
References
- Supreme Court of India, Criminal Original Jurisdiction. Writ Petition (Criminal) No. 115 of 2009. Available from: https://api.sci.gov.in/jonew/judis/37709.pdf, accessed on December 17, 2025.
- Supreme Court of India. Government of India. Common Cause (A Registered Society) v. Union of India & Another, (2018) 5 SCC 1. Available from: https://cdnbbsr.s3waas.gov.in/s3ec0490f1f4972d133619a60c30f3559e/documents/aor_notice_circular/44.pdf, accessed on December 17, 2025.
- Supreme Court of India. Order modifying advance medical directive/withholding and withdrawing of life-sustaining treatment procedures (Common Cause case). Miscellaneous Application No. 1699 of 2019 in Writ Petition (Civil) No. 215 of 2005. Order dated 24 Jan 2023. New Delhi: Supreme Court of India; 2023. Available from: https://main.sci.gov.in, accessed on December 29, 2025.
- Government of Karnataka, Urban Development Department. Proceedings of the Government of Karnataka Government Order No. UDD 184 BBL 2024. Available from: https://hfwcom.karnataka.gov.in/334/government-orders/en, accessed on Decmber 5, 2025.
- Government of Karnataka. Circular No. HFW 256 FPR 2024: Salient features of the orders of the Hon’ble Supreme Court dated 24 Jan 2023 in Miscellaneous Application No. 1699 of 2019 in Writ Petition (Civil) No. 215 of 2005 with regard to withholding/withdrawing of life-sustaining treatment (WLST). Bengaluru: Department of Health and Family Welfare; 2025 Jan. Available from: https://hfwcom.karnataka.gov.in/storage/pdf-files/SalientFeaturesofSCJudgmntonWLST_merged.pdf, accessed on December 29, 2025.
- Health and Family Welfare Department (Karnataka). Nomination of registered medical practitioners to the secondary medical board to certify withholding/withdrawing of life-sustaining treatment (WLST) [Internet]. Bengaluru: Health and Family Welfare Department; 2025 Jan 30. Available from: https://hfwcom.karnataka.gov.in/storage/pdf-files/NomineeofDHOonSecondaryBoard-1-1.pdf, accessed on December 29, 2025.
- Government of Karnataka, Department of Rural Development and Panchayat Raj. Notification No. RDPR 729 GPA 2024. Bengaluru: Government of Karnataka; 2025 Feb 14. Available from: https://rdpr.karnataka.gov.in/storage/pdf-files/Panchayatraj/No_729_24_14_02_25.pdf, accessed on December 29, 2025.
- Government of Karnataka, Urban Development Department. Corrigendum to Government Order No. UDD 184 BBL 2024. Bengaluru: Government of Karnataka; 2025 Feb 15. Available from: https://hfwcom.karnataka.gov.in/uploads/udd%20184%20bbl%202024%20corregendum%20Tranlate_1767521190.pdf, accessed on December 17, 2025.
- Ministry of Home Affairs, Government of India. Overseas Citizenship of India (OCI) cardholder – frequently asked questions (FAQs). New Delhi: Ministry of Home Affairs; 2021 Jul 22. Available from: https://www.mha.gov.in/sites/default/files/2022-09/OCIFAQs_23072021%5B1%5D.pdf, accessed on December 29, 2025.
- Directorate General of Health Services, Ministry of Health and Family Welfare. Circular on implementation of Supreme Court guidelines on withdrawal of life support. New Delhi: Ministry of Health and Family Welfare; 2023. Available from: https://dghs.mohfw.gov.in/uploads/assets/Ym7COsjGbBsOkMxYuLRUlrO3j3ZE0Bn7HTXpuyDV.pdf, accessed on December 29, 2025.
- Definition of terms used in limitation of treatment and providing palliative care at the end of life: The Indian council of medical research commission report. Indian J Crit Care Med.. 2018;22:249-62.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- ICMR consensus guidelines on do not attempt resuscitation. Indian J Med Res.. 2020;151:303-10.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Palliative performance scale (PPS): A new tool. J Palliat Care.. 1996;12:5-11.
- [CrossRef] [PubMed] [Google Scholar]
- Validation of the Addenbrooke’s cognitive examination III in frontotemporal dementia and Alzheimer’s disease. Dement Geriatr Cogn Disord.. 2013;36:242-50.
- [CrossRef] [PubMed] [Google Scholar]
- ICU admission for cancer patients with respiratory failure: an ethical dilemma. Rev Mal Respir.. 2023;40:692-99.
- [CrossRef] [PubMed] [Google Scholar]
- Drivers of burnout among critical care providers: A multicenter mixed-methods study. Chest.. 2022;161:1263-74.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Reducing futile acute care services for terminally Ill patients with cancer: The dignity project. JCO Oncol Pract.. 2021;17:e1794-802.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Critically ill patients’ experiences of discomfort and comfort in the intensive care unit: A qualitative descriptive study. Aust Crit Care.. 2025;38:101115.
- [CrossRef] [PubMed] [Google Scholar]
- Enhancing advance care planning in India through a 12-step Pathway. Indian J Crit Care Med.. 2025;29:301-7.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Simplified legal procedure for end-of-life decisions in India: A new dawn in the care of the dying? Indian J Crit Care Med. . 2023;27:374-6.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Navigating tensions when life-sustaining treatment is withdrawn: a thematic synthesis of nurses’ and physicians’ experiences. J Clin Nurs.. 2024;33:2337-56.
- [CrossRef] [PubMed] [Google Scholar]
- Withdrawal of life-sustaining therapies for awake patients in critical care: The benefits of a collaborative intensivist and palliative care approach. J Intensive Care Soc.. 2025;26:353-62.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- India. The Transplantation of Human Organs and Tissues Act, 1994 (as amended up to Act 16 of 2011). New Delhi: Government of India, Legislative Department; 1994.
- Life before death in India: A narrative review. Indian J Palliat Care.. 2023;29:207-11.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Advance care planning and the ethical obligation of death literacy as a public health initiative in India. Indian J Med Ethics.. 2024;IX:308-12.
- [CrossRef] [PubMed] [Google Scholar]