INDIAN PEDIATRICS 409
VOLUME 48__MAY 17, 2011
C O R R E S P O N D E N C E
I read with interest the article by Kaushik, et al. . The authors have covered the topic in all the aspects where an act of commission is required by the doctors. However, I would like know whether an informed consent is necessary when withdrawing life support in abraindeadpatient. Isitappropriatethatthefamily is explained the irreversibility of the situation and futility of further treatment, and informed consent to withdraw life support is taken?
Syed Ahmed Zaki
Department of Pediatrics, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai 400 022, India. firstname.lastname@example.org
1. Kaushik JS, Narang M, Agarwal N. Informed consent in pediatric practice. Indian Pediatr. 2010;47:1039-46.
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) . 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 . 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 medi- cations and slow de-escalation of treatment [3, 4].
Jaya Shankar Kaushik and Manish Narang
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: http://www.lawcommissionofindia.nic.in/reports/rep196. pdf. Accessed on December 26, 2010.
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: http://www.supremecourtofindia.nic.in/outtoday/ wr1152009.pdf. Accessed on March 17, 2011.
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.
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.