Advance Directives — Current Status in India

An advance directive (AD) is a legal document that allows a patient to convey decisions about the care they want if they later become unable to express their wishes.

Purpose: it makes the person think about care preferences before a crisis, simplifies decision-making, and lets the family feel confident they did what the patient wanted regardless of their own beliefs.

Two main types: Living will — specifies care preferences in a terminal state or vegetative state, usually covering CPR, intubation, artificial nutrition and hydration, dialysis and IV therapy. Durable power of attorney for health care (proxy/agent) — appoints a person to make decisions on the patient's behalf.

Limitation of the living will: it addresses only a few defined clinical situations. It cannot decide the nuanced questions, such as when an antibiotic is life-supporting versus comfort care.

Components of a durable power of attorney (Table 17-2): statement of intention citing the enabling statute; designation of the agent with contact details; general statement of the authority granted; statement of desires, special provisions and limitations; dated signature; and witnesses — who must NOT be the agent, healthcare providers, or employees of the facility giving care.

Decision standard for the proxy: use substituted judgment (what the patient would have wanted); where uncertain, fall back on beneficence — weighing benefits against burdens.

Who should be proxy? Not automatically the next of kin, but the person who best knows the patient's preferences — which may be a close friend or clergyman rather than a rarely seen relative.

Pitfalls: agents may pursue their own interests; surrogate decisions may be incongruent with the patient's actual wishes; decisions once made are hard to revoke; and there is no reliable test of capacity to decide whether someone can change their mind.

Key clinical caution: making end-of-life judgments while in good health is difficult. Do not assume the old-old are "ready to die." What a patient wants at 85 may differ from what they want at 97 — so discussions must be ongoing, not one-off.

POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment) convert an AD into an actionable standing medical order, particularly for those who want to avoid life-sustaining treatment, live in long-term care, or may die within the next year.

Legislation alone does not work: the US Patient Self-Determination Act (1991) mandated that all persons entering a hospital or nursing home be offered the opportunity to make an AD, yet it had minimal impact on the number actually completing one.

A trial of therapy is permissible — patients and families must be told that a treatment once started need not be continued indefinitely.

Aruna Shanbaug v. Union of India (2011) — the Supreme Court permitted passive euthanasia for the first time in India.

Common Cause (A Regd. Society) v. Union of India (2018) 5 SCC 1 — a five-judge Constitution Bench held that the right to die with dignity is a fundamental right under Article 21. It legalised passive euthanasia and gave legal recognition to Advance Medical Directives (AMD).

The 2018 procedure proved unworkable — it required countersignature by a Judicial Magistrate First Class (JMFC) plus two layered medical boards, causing delays that defeated the purpose.

Common Cause (Modification Order), 24 January 2023 — following a Miscellaneous Application by the Indian Society of Critical Care Medicine, the Supreme Court substantially simplified the procedure. This 2023 order is the operative law today. Requirements of a Valid AMD in India (Post-2023)

Must be executed by an adult with decision-making capacity, voluntarily and without coercion, and be in writing.

Must state in unambiguous terms the decision to withhold or withdraw treatment, and specify the circumstances in which it applies.

Must be signed in the presence of two attesting witnesses and attested by a Notary or a Gazetted Officer — the JMFC requirement has been removed.

Must nominate at least two guardians or close relatives empowered to give consent, and a copy must be given to the nominated persons, the family physician and the local custodian.

Revocable at any time before implementation. An AMD does not apply if circumstances have arisen that the executor did not anticipate and which would have altered the decision.

Applies only to terminal illness with no hope of recovery, or persistent vegetative state.

Primary Medical Board — constituted by the hospital, minimum three treating doctors. If it certifies the patient is terminal/irreversible, the case goes to the Secondary Medical Board, which must decide within 48 hours. The Chief District Medical Officer nominates one member of the Secondary Board.

Where there is NO advance directive, the same medical board procedure applies with the consent of the family/surrogate — High Court permission is no longer routinely required.

Passive euthanasia (withholding/withdrawing life-sustaining treatment) is LEGAL. Active euthanasia and physician-assisted suicide remain ILLEGAL under the Bharatiya Nyaya Sanhita provisions on abetment of suicide and culpable homicide.

A separate and independent framework exists under Section 5 of the Mental Healthcare Act, 2017, which permits advance directives for mental health treatment. The two frameworks are not interchangeable.

A patient refusing life-sustaining treatment remains fully entitled to palliative care — withdrawal of LST is never withdrawal of care.

The 2023 Modification Order — what actually changed. The clarification order removed the requirement of Magistrate attestation, replaced the earlier two-board arrangement with a streamlined board of three doctors, allowed hospital ethics committees to participate, and introduced digital registration and storage. The current position is that a valid Indian AMD requires written form, two witnesses, and attestation by a Notary or Gazetted Officer, and should be accessible to the nominated person and to the treating physician. (Common Cause v. Union of India, 2023 SCC OnLine SC 99, decided 24 January 2023)

MoHFW draft guidelines for withdrawal of life support (September 2024). The Ministry issued draft guidelines translating into clinical reality the streamlined procedure set out by the Supreme Court. Terminal illness is defined as an irreversible or incurable condition from which death is inevitable in the foreseeable future, and severe brain injury with no recovery after 72 hours is included. Doctors are advised to base the decision on factors including declaration of brainstem death, poor prognosis with no likely benefit from treatment, or documented informed refusal by the patient or family. The end-of-life care pathway is adapted from the ISCCM– IAPC Expert Consensus and Position Statements for End of Life and Palliative Care in the ICU.

State-level operationalisation — the real bottleneck. Karnataka became the second state after Kerala to implement the order, with a Health Department circular of 30 January 2025 mandating primary and secondary medical boards in hospitals to review WLST requests based on living wills, together with a state AMD format; the Indian Association of Palliative Care noted this made Karnataka the first state government in India to make the WLST process feasible statewide, with the secondary medical board required to confirm or refuse within 48 hours. Goa became the first state to fully operationalise the AMD facility, with a Bombay High Court judge executing the first living will before two witnesses and a gazetted officer.

Persistent implementation problems. The orders require an officer of the local government to be nominated as "custodian" of all advance medical directives, but have proved challenging: decisions about withholding or withdrawing life-sustaining treatment often need to be made within hours, assembling six different medical experts in that time is difficult especially in non-urban settings, and it is impractical to approach the district Chief Medical Officer to nominate a Secondary Medical Board member for every such decision.

Supporting ICMR documents. Two ICMR publications — on definitions of terms used in limitation of treatment, and on Do-Not-Attempt-Resuscitation — clarified terminology and helped standardise and remove ambiguity around terminal illness, withholding/withdrawal, and end-of-life care. (Indian Journal of Medical Research 2020 and 2026)

"The right to die with dignity is a fundamental right under Article 21 — Common Cause v. Union of India, 2018."

"The 2023 Modification Order removed the Judicial Magistrate requirement; an AMD now needs only two witnesses and attestation by a Notary or Gazetted Officer."

"Withdrawal of life-sustaining treatment is never withdrawal of care — palliative care continues in full."

Numbers You Must Not Get Wrong Item Value Hayflick limit ~50 population doublings Hallmarks of ageing 9 (2013, in Pathy's) → 12 (2023)

Named Trials and Studies Trial Field Result to quote CALERIE Caloric restriction 25% CR × 2 yr slowed DunedinPACE ~3%; no change in PhenoAge/GrimAge DPP / DPPOS Metformin as geroprotector 21-yr follow-up: no multimorbidity benefit; lifestyle superior TAME Metformin Awaited — definitive geroprotector trial SToMP-AD / STAMINA Senolytics Dasatinib + quercetin Phase 1 safe; TNF-alpha fall correlated with MoCA gain ZEUS IL-6 inhibition Ziltivekimab, n = 6376: HR 0.99 — no MACE benefit despite hsCRP fall CANTOS IL-1beta inhibition Canakinumab reduced incidence of age-related diseases SAPHYR PMR Sarilumab sustained remission 28% vs 10% at 52 weeks CAPITA Pneumococcal PCV13 reduced pneumococcal pneumonia by 45% DANFLU-2 Influenza n = 332,438: high-dose missed primary endpoint; cardiorespiratory rVE 5.7% EPIDOS Fracture Inactivity RR 2.2 > low BMD RR 1.4 for humerus fracture Look AHEAD Weight loss Risk factors improved but no CV event reduction TONE Hypertension Salt restriction + weight loss lowers BP in older adults FINGER Multidomain First multidomain dementia prevention trial; 7/10 trials positive in the 2020s NU-AGE Diet Mediterranean diet promotes epigenetic rejuvenation KEEPS / WHI HRT HRT not recommended after age 60 VIVIFRAIL Exercise Individualised passports by SPPB + gait speed; protected residents in COVID confinement Fiatarone 1990 Exercise High-intensity resistance training effective in nonagenarians Roberts et al. Caloric restriction Old men fail to compensate after underfeeding; never regain weight 3. Classifications and Frameworks Framework Contents Theories of ageing Error/stochastic • Programmed • Evolutionary Evolutionary theories Medawar (mutation accumulation) • Williams (antagonistic pleiotropy) • Kirkwood (disposable soma) 9 hallmarks (2013) Primary: genomic instability, telomere attrition, epigenetic alterations, loss of proteostasis. Antagonistic: deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence. Integrative: stem cell exhaustion, altered intercellular communication 3 added in 2023 Disabled macroautophagy • chronic inflammation • dysbiosis Epigenetic clock generations 1st Horvath/Hannum (chronological age) • 2nd PhenoAge/GrimAge (mortality) • 3rd DunedinPACE (pace) Intrinsic capacity domains Cognition • psychological • sensory (vision, hearing) • vitality/nutrition • locomotion Active ageing pillars Health • Participation • Security UN Decade action areas Ageism • age-friendly environments • integrated care • long-term care Health Maintenance Glidepath Robust • Frail • Moderately demented • End of life World Falls Guidelines risk Low • Intermediate (fall + gait/balance problem) • High (injury, ≥2 falls, frailty, long lie, TLoC) Ageism (3 components) Stereotyping (think) • prejudice (feel) • discrimination (act) Indian AMD requirements Written • adult with capacity • two witnesses • Notary OR Gazetted Officer • two nominees 4. Mnemonics and Memory Hooks Hook Use "MWK" Medawar – Williams – Kirkwood: the three evolutionary theories, in order "Stand → Stay → Stride" Exercise sequence in the frail: strength/power → balance → endurance "Quantity kept, quality lost" Vaccine failure in the elderly: IgG normal, IgM/opsonisation defective 4 ways to beat Adjuvant • higher dose • recombinant/conjugate • vaccinate the carers (cocooning) immunosenescence "IL-6 → hepcidin → ferroportin The whole pathogenesis of anaemia of chronic disease in one line block" "Double-edged telomere" Short = degenerative disease; long = cancer permitted "Healthspan, not lifespan" The correct verdict on sirtuins, resveratrol and most geroprotectors "Function, not diagnosis" The organising principle of healthy ageing and of geriatric assessment "2018 → 2023" India: right recognised (Common Cause) → procedure made workable (Modification Order)

Guidelines and Documents to Cite by Name Cell 2023 — Hallmarks of aging: an expanding universe (12 hallmarks) Nature Medicine 2024 — Biomarkers of Aging Consortium validation framework Nature Aging 2023 — CALERIE / DunedinPACE Lancet Commission 2024 — dementia prevention, 14 risk factors, ~45% preventable WHO ICOPE Handbook, 2nd edition (2024) + ICOPE App WHO / UN Decade of Healthy Ageing 2021–2030 — four action areas; mid-term evaluation 2026 World Falls Guidelines 2022 (Age and Ageing) + AGS response 2024 (JAGS); STOPPFall Izquierdo 2024 — ICFSR global exercise recommendations for longevity ACIP / MMWR 2025 — pneumococcal from age 50; RSV at 75+ and risk-based 50–74 EWGSOP2 — sarcopenia cut-offs; GLIM — malnutrition diagnosis Common Cause v. Union of India (2018) 5 SCC 1 and 2023 SCC OnLine SC 99 (Modification Order) MoHFW Draft Guidelines for Withdrawal of Life Support in Terminally Ill Patients (Sept 2024) ISCCM–IAPC Position Statement on End of Life and Palliative Care in the ICU ICMR — Definitions in limitation of treatment; Consensus guidelines on DNAR Mental Healthcare Act 2017, Section 5 — advance directive for mental health treatment The Twelve One-Liners — If You Read Nothing Else

Ageing is a failure to maintain homeostasis under physiological stress.

Chronological age is only a surrogate; gait speed predicts mortality better than hypertension.

Telomere shortening protects against uncontrolled division — at the expense of ageing.

Sirtuin modulation does not extend lifespan in mammals; it expands healthspan.

Plasma IL-6 rises with normal ageing and correlates inversely with functional ability.

In vaccine failure, antibody quantity is preserved but antibody quality is lost.

Older adults do not compensate after underfeeding — they never regain the lost weight.

Exercise is the only proven anti-ageing intervention; every geroprotector remains investigational.

Healthy ageing is defined by function, not by the absence of disease.

"Active" means continued participation — not merely being physically active.

Frailty is not a contraindication to robust exercise; it is the strongest indication for it.

Withdrawal of life-sustaining treatment is never withdrawal of care.