New Delhi: Critically ill patients should not be admitted to Intensive Care Units (ICUs) if they or their next of kin refuse the intensive treatment or if they have any disease with a treatment limitation plan that indicates ICU interventions will not be beneficial. This is among the key recommendations in the first ever guidelines by the Union Ministry of Health and Family Welfare on ICU admission and discharge, released last month.
The guidelines adopted for India after studying similar norms around the world, however, are only advisory in nature and are not binding on hospitals or doctors.
The recommendations, prepared by critical care specialists from the government and private sectors also say that anyone with a ‘living will’ or advanced medical directive (AMD) against ICU care should not be administered intensive care while those who do not benefit from aggressive care should be discharged.
According to Investopedia, a living will is a legal document detailing the type and level of medical care a patient wants to receive if they are unable to make decisions or communicate their wishes when care is needed.
While recognising the right to die through a landmark ruling in 2018, a constitution bench of the Supreme Court laid down guidelines for terminally ill patients to enforce the right, through an advance medical directive or living will. This came a year after the Supreme Court upheld the right to privacy as a fundamental right.
In the historic Aruna Shanbaug case in 2011, the apex court had permitted passive euthanasia in India, saying that it was only possible under a stringent court procedure.
The recognition of passive euthanasia by the apex court implied that doctors can withhold or withdraw treatment from such patients after following due protocol.
Dr Raj K. Mani, a Delhi-based intensivist who was instrumental in fighting for better norms and dignity around end-of-life care in the Supreme Court, told ThePrint that the latest guidelines are crucial as ICU care is a valuable, expensive, and scarce resource.
“So it must be used with due care. Without best practices guidelines, utilisation of the ICU can be arbitrary and subject to misuse,” Mani, who was also on the committee of the experts which framed the recommendations, said.
He also stressed that ICU care and high-tech interventions are meant for patients who have a reasonable chance of benefiting from it, and those who are suffering from a terminal illness or are dying from incurable conditions do not.
“In fact, their suffering may only be aggravated and prolonged by life-sustaining treatments as they die lonely in a medicalised environment when they need their family and familiar environment around them,” he said, adding that instead, such patients need palliative care and “a spiritual atmosphere”.
ThePrint explains what the latest suggestions on ICU hope to achieve and what they say.
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ICU care only for ‘clinical reasons’
The guidelines say that patients with an altered level of consciousness or with a recent onset hemodynamic instability — such as shock and irregular heartbeat — and those with acute illness requiring intensive monitoring or organ support should be given ICU care.
This list also includes patients with medical conditions or diseases with anticipation of deterioration, those who have experienced any major intraoperative complication, and those who have undergone a major surgery.
But terminally ill patients with a medical judgment of futility should not be offered ICU interventions, the guidelines clearly state. The exclusion criteria also include low-priority criteria in case of a pandemic or disaster situation where there are resource limitations.
They also dwell upon the need to immediately discharge patients in case of return of physiological aberrations to near normal or baseline status and reasonable resolution and stability of the acute illness, and in cases where the patient or family agrees for ICU discharge for a treatment-limiting decision or palliative care.
The advisory also specifies the minimum standard of monitoring required while awaiting an ICU bed and the minimum stabilisation required before transferring a patient to the ICU.
The guidelines were necessitated as ICU care in several cases imposed unjustifiable emotional and financial burdens on families of patients who are terminally ill or having the last stages of an incurable illness, Mani told ThePrint.
There is another intended benefit from the new suggestions. “Since ICU beds may be filled with those who are for terminal care, many patients with curable ailments may be denied life-saving care. Following the latest advisory will prevent such a scenario,” Mani insisted.
Who can provide ICU care?
According to the guidelines, a specialist who has specific training, certification, and experience in managing critically ill patients in an ICU has been categorised as an intensivist or critical care specialist.
But in case of doctors not having the requisite qualifications or training, those with extensive experience in intensive care in India after MBBS — quantified as at least three years’ experience in ICU — can also work as an ICU doctor.
According to Dr Dhruva Chaudhary, a critical care specialist from Haryana who was also behind framing the guidelines, this definition was particularly important for India beyond Tier 1 and 2 cities.
“Looking at the ground reality, experience has been given due weightage to define intensivist so that even mofussil towns can get emergency and Intensive care,” Chaudhary told ThePrint.
The rationale behind the guidelines was to streamline the process of admission and discharge in the ICU, he said.
“There is a debate about who should and should not receive ICU care. We have tried to find a path that is simple, practical, and actionable across the country and gives sufficient autonomy to both clinician and patients and their caregivers to make an informed decision,” the intensivist said.
(Edited by Uttara Ramaswamy)
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