Living will, ICU care, and what death with dignity means in India

Kumar,* a 68-year-old man with stomach cancer, began treatment at a tertiary-care centre in Bengaluru in December 2025. Over the next few months, the disease progressed despite treatment, and the risks of further cancer-directed treatment came to outweigh its likely benefits. More side effects meant worse quality of life and an inability for him to do things he enjoyed. He then spent three weeks in intensive care due to sepsis, leading to several complications. Kumar survived, but left the hospital much weaker and was referred to the palliative care team.

His family wanted him to continue receiving appropriate care, but wondered whether another ICU admission would cause more of a decline in health and only give him a few additional days without any meaningful time. Kumar repeatedly asked to return to his home town near Darjeeling. His family understood that he wanted to be near his community and have his faith rituals of Buddhism observed upon his passing.

The palliative care team arranged a discussion with the lead intensivist, who agreed that another ICU stay was not the answer. Kumar’s priorities and the clinical recommendation against further escalation were recorded in an advanced care plan that documented his current and future care needs. His family also found a local doctor willing to care for him closer to home.

Palliative care did not overrule intensive care in this case, nor was an ICU admission simply denied. The treating clinicians reached a shared recommendation, the patient’s priorities were made visible, and another doctor who could understand the plan was found. A decision that might otherwise have been made during the next emergency was considered beforehand.

This is one person’s story that poses an important question: When does a patient need intensive care, and when can it be decided that they must not continue with life support in the ICU?

Where intensive care helps

Intensive care is medicine organised for rescue. Life support machines aid failing organs while other treatments work, the body recovers itself, or doctors learn more about disease progression. Within limits, a ventilator can sustain the lungs through severe pneumonia; dialysis can support injured kidneys; vasopressors and close monitoring can help a patient survive septic shock or other conditions where the heart fails. For many patients, the purpose of an ICU is clear and the benefit considerable.

However, sometimes the patient may not improve as expected and the underlying disease continues to progress, or the immediate crisis may reveal how far an illness has advanced. In other cases, there might be no possibility of meaningful recovery but the patient may be kept in the ICU on machines for an extended period. The question then becomes whether the purpose of the treatment remains achievable in light of what is now known.

The Government of India’s 2023 ICU admission and discharge guidelines emphasise treatment for a reversible problem, the expected benefit of intensive care, evaluating patient preferences, and weighing lack of benefit from continued aggressive treatment.

Serious illness changes the future a person had imagined; a good decision must therefore consider not only how long treatment may sustain the body, but also what kind of life it may make possible.

This decision is not of one person alone, especially if a patient is unconscious or unresponsive. The specialist may understand their underlying disease, the nurse may be monitoring their state every hour, and the family might know what kind of further treatment or recovery the patient would want. Sharing this knowledge with one another can guide decision-making around limiting or shifting the goals of care—whether continuing aggressive efforts or focusing on comfort and mitigating further suffering. 

There are medical, ethical, financial, and emotional consequences for both the hospital and the families otherwise. A bed occupied by a patient for a prolonged duration when they are unlikely to benefit further from intensive care is a bed that isn’t available for someone with a treatable condition—a consideration that goes beyond the hospital’s profit margins alone.

Insurance coverage is a financial question, while whether treatment still benefits the patient is a medical and ethical one.

For families, the financial burden can often become overwhelming. Private ICU care in India can cost anywhere between INR 15,000 and INR 1 lakh per day, depending on the city, hospital, and whether a ventilator or life-support device is involved. Further, there’s income loss due to insurance sub-limits and waiting-period exclusions, and the time family members stay away from work to be by the patient.

At the same time, families with health insurance might understandably feel that cost isn’t something they need to worry about. But insurance coverage is a financial question, while whether treatment still benefits the patient is a medical and ethical one. These two questions can easily become tangled for families, so it may help to gently separate them early on.

As these big questions and uncertainties can evolve quite fast in an ICU, having support staff available for these conversations, and integrating the palliative care team in the ICU itself, can help families navigate these situations with more clarity and care. This is also reflected in a joint statement by the Indian Society of Critical Care and the Indian Association of Palliative Care, which cautions against unilateral decisions, and asks intensivists to lead multidisciplinary and family meetings, offer considered recommendations, and avoid transferring the full burden of a treatment-limiting decision on to the family.

Planning for uncertainty

What can help in decision-making is planning before a crisis happens, or planning contingencies for best and worst case when the situation is actively evolving. The former allows the patient and their family to exercise autonomy when they feel that intensive care is no longer serving them. This is known as advance care planning. 

Advance planning can take two related forms:

• An advance medical directive (AMD), often called a living will, is a formal document made while a person has decision-making capacity. It records how the person would wish to be treated, or not treated if they later become incapacitated, and identifies those authorised to represent their wishes.
• A documented treatment plan serves a more immediate clinical purpose. Developed during serious illness, it records the patient’s or family’s preferences, the goals of treatment, the treating team’s recommendations, and the conditions for review. When a patient’s capacity is lost, this helps in providing important evidence of their previously expressed wishes, but does not by itself become a formally executed AMD.

Work is still underway to make advance planning more accessible in India. A multidisciplinary group supported by the Indian Council of Medical Research’s Bioethics Unit has published a 12-step pathway for creating, reviewing, and implementing directives, while hospitals have begun establishing living-will clinics to help people turn their preferences into actionable documents. These directives are critical in mitigating the fear and uncertainty that emerge when a family may have to decide whether to continue, shift, or withdraw care on the patient’s behalf.

How Indian law supports the right to die with dignity

For almost a decade, India’s laws have been evolving to answer a central question: When continuing aggressive treatment no longer helps a patient, can it be stopped, and how? This is in turn connected to the right to die with dignity and the responsibility of care beyond treatment—where palliative care plays a key role.

Three significant moments have shaped this conversation.

1. Recognising the right to die with dignity as a fundamental right

Under the Common Cause vs Union of India 2018, the Supreme Court of India ruled that the right to die with dignity is a fundamental right under Article 21 of the Constitution, which includes the right to refuse treatment and to prepare a living will.

2. Simplifying the process of executing an AMD

The original process of executing a living will was quite complicated, which led to the Supreme Court’s modification order for AMDs in 2023 that reduced bureaucratic hurdles.

For families, this means flexibility in appointment of guardians, digitised health records for ease of access, and a prescribed timeline within which the hospital must respond to their request to execute an AMD. These requests are assessed and approved by a primary medical board (PMB) constituted of doctors directly involved in the patient’s care and validated within 48 hours by a separate secondary medical board (SMB) comprising senior clinicians who are not directly involved in the patient’s care, at least one of whom has been nominated by the chief medical officer of the district and who may or may not be affiliated with the same hospital. Both the PMB and SMB may thus be constituted at the hospital level, helping to ensure that families and medical professionals are able to make timely decisions around care. However, the work for appointing SMBs is still ongoing, so families can appeal to the concerned state’s high court in case the PMB/SMB is not constituted as per law; if decisions are delayed beyond the prescribed limits; or if there is fundamental disagreement between family and medical recommendation.

3. Clarifying the withdrawal of life support

In the landmark Harish Rana vs Union of India 2026 case, the Supreme Court approved the withdrawal of life support for Harish Rana, who had been in an unresponsive, vegetative state for 13 years. Crucially, the case had wider significance for the withdrawal of treatment and the continuity of care:

• The court permitted withdrawal of clinically assisted nutrition and hydration, holding that it constituted medical treatment instead of ‘basic care’, and directed that withdrawal occur with palliative care.
• If a patient is unable to speak for themselves and does not have a living will, thinking of their best interest—that is, evaluating if there is any real benefit left in continuing treatment—can be considered while making a decision about the next steps.
• Stopping treatment is not abandoning the patient. The court was explicit that once treatment is withdrawn, the hospital’s duty of care continues.

The law now allows doctors and families to withhold and withdraw life-sustaining treatment in an ethical, medically appropriate, and legally grounded way. Palliative care can contribute without assuming control in these situations. It may relieve symptoms, clarify what matters to the patient, and support difficult conversations.

How patients and families can initiate a shift in the course of care

When a patient has no chance of meaningful recovery, and they wish to transition away from aggressive life-sustaining measures, families can ask the medical team certain questions to support decision-making:

1. Which parts of the patient’s condition are reversible, and what is intensive treatment expected to achieve?
2. How likely is that outcome, and how and when will the team judge whether treatment is working?
3. Based on the patient’s condition and priorities, what does the treating team recommend?
4. How will symptoms and comfort be managed based on whatever decision is made?
5. What will treatment cost, and what is covered by insurance?

More importantly, it is the responsibility of the hospital and the medical team to proactively offer families this information, especially in cases where they might be unaware of these provisions. 

A framework for hospitals to plan in advance

For doctors, nurses, and administrators, the AMD framework provides legal clarity and protection. When accompanied with more structured and ongoing reviews of the patient’s condition, it can support decision-making in cases where the illness’ trajectory or the patient’s wishes are unclear. Here’s how hospitals can put this into practice:

1. Document the purpose of treatment, the patient’s priorities, the agreed plan, and how and when it will be reviewed. Define prompts for review, such as a prolonged or repeated ICU admission, marked functional decline, an uncertain trajectory, an existing advance plan, or a request from the patient, family, or treating clinician.
2. Build a real palliative-care pathway. If and when families ask for treatment to be withdrawn, hospitals often use the ‘discharge against medical advice (DAMA)’ reasoning. This form is issued in cases where patients are on life support, and families choose to take them home after doctors indicate that no further curative treatment is possible. In the Harish Rana case, the Supreme Court criticised this, explicitly stating that stopping treatment must be followed by humane, symptom-focused assistance through palliative care, instead of shifting responsibility away from the healthcare institution. The treating team must bring in palliative care and other specialists to discuss the course of action. A decision not to escalate treatment must still include symptom management, communication, family support, and a safe plan for care inside or outside the hospital.
3. Maintain the primary medical board, composed of the treating team, and the secondary medical board as standing institutional structures within the hospital. These bodies must remain prepared to assess the patient’s condition and confirm whether the AMD can be executed. This process is meant to protect clinicians who follow it in good faith, and also provides a structured alternative to using DAMA as a workaround, allowing a real palliative plan to be delivered instead.
4. Ensure that your state has notified the required medical panels at the district level. In order to implement the Supreme Court’s 2023 directives to execute AMDs, state governments have to activate the secondary medical boards at the district level. Karnataka, for instance, started this work in 2025.
5. Train staff to have a conversation with the family before an emergency, ensuring that they are prepared. Structured family meetings, ideally within the first 72 hours of an ICU admission, and again if the stay crosses 10–14 days, give families time to process the situation rather than feeling ambushed by a decision at an emotionally difficult time. This also helps reduce moral distress among ICU staff, which is a well-documented contributor to burnout in critical care.

Death in dignity requires care, comfort, and the ability to make a choice. For families, the living will framework offers a way to choose comfort and dignity for a loved one without guilt, legal ambiguity, or having to fight an imposing medical system. For the medical staff, it offers protection and clarity to act on what they believe is right.

*Name changed to maintain confidentiality.

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Know more

• Learn how panchayats can foster a culture of palliative care.
• Read more about how to make a living will.
• Learn more about end-of-life care through this toolkit.