Denial of intubation & Ventilation in the end of life

Dignified death is everyone's right and ine should have the right to choose the way he wants his last days should be spent. A good death is the one at home with loved ones not in icu with ventilator. Adding miserable days of life in icu only prolongs agony not the life and also it's an economic burden not only to the family but the country too.

1. Denial of intubation & Ventilation-Case Scenarios Dr Naine Bhadrala Associate Professor Deptt . Of Anesthesia GMC Jammu

2. QUALITY OF DEATH INDEX   India  ranked 59th  among  80  countries in the world in a survey in 2022

3. Denial of intubation and mechanical ventilation can occur in two primary ways : The patient refuses intubation The healthcare team denies intubation

4. Patient Refuses Intubation A 75-year-old male with end-stage COPD and a history of multiple ICU admissions for respiratory failure presents to the emergency department with severe dyspnea and hypercapnia . The medical team determines that he requires intubation and mechanical ventilation to survive. However, the patient previously signed an advanced directive stating he does not want to be intubated . Despite family members urging intervention, the patient, who is still alert and oriented, reaffirms his decision to decline intubation. Healthcare Team Denies Intubation A 90-year-old female with metastatic cancer, severe heart failure, and multiple organ failure is admitted to the ICU in respiratory distress. The ICU team assesses her prognosis as poor, with little chance of meaningful recovery. The family insists on full resuscitation, including intubation and ventilation, but the medical team believes it would be futile and prolong suffering. They recommend comfort measures instead Case Scenario-1 Case Scenario-2

5. Ethical and Legal Aspects Case 1 Patient Autonomy & Informed Consent A competent adult has the right to refuse medical treatment , even if it leads to death. Informed refusal : The patient must understand the risks of declining treatment. Exceptions: If the patient lacks capacity (e.g., confusion, delirium, unconsciousness), their wishes might be overridden if no advance directive exists. In emergencies where the patient’s preferences are unknown, doctors assume the best interest standard and proceed with life-saving care. Advance Directives & Legal Standpoint Advance directives (living wills, POLST, DNAR orders) guide medical teams in honoring patient wishes. If a patient verbally changes their mind , their current decision overrides written documents.

6. Real-World Challenges & Communication Strategies Family Disagreement: Family members often struggle to accept a patient’s refusal of intubation. Solution: Use structured conversations . Non-Invasive Alternatives: Offer alternatives like BiPAP /CPAP for respiratory support without intubation. Comfort measures: Oxygen, morphine, and sedation for air hunger

7. Ethical & Clinical Considerations Case 2 Medical Futility: When is Intubation Not Justified? Medical futility is when an intervention offers no meaningful benefit or prolongs suffering without improving quality of life . Situations Where Intubation May Be Denied: End-stage diseases Mass casualty/disaster scenarios Persistent vegetative state with no hope of recovery .

8. Ethical Balancing: Beneficence vs. Non- Maleficence Beneficence (do good) → Provide care that improves quality of life. Non- Maleficence (do no harm) → Avoid prolonging suffering with futile interventions. Justice (resource allocation) → In ICU settings, beds and ventilators are limited; priority may go to patients with higher survival chances.

9. Communication Strategies in Denying Intubation Family Engagement: Use shared decision-making : Explain that intubation will not change the outcome . Emphasize comfort-focused care rather than aggressive interventions. Use phrases like: "We want to ensure dignity and comfort in your loved one's final moments." "We are not giving up; we are shifting to compassionate care.“ Involve Palliative Care Early Families often feel abandoned when life-prolonging measures are stopped. Palliative teams help transition care toward comfort and emotional support.

10. Example Case: A 98-year-old woman with severe Alzheimer’s, bedridden for years, and multiple organ failure is brought to the ER in respiratory distress. Her son demands intubation, but the ICU team determines ventilation would be futile . After extensive discussions, the family agrees to comfort care , and she receives oxygen, morphine, and sedation instead of aggressive interventions.

11. Factor Patient Refuses Intubation Healthcare Team Denies Intubation Ethical Principle Autonomy Medical Futility Key Challenge Family disagreement, fear of death Family insistence on aggressive care Legal Issue Patient’s right to refuse vs. family pressure Risk of legal action for withdrawing care Outcome Options Respect refusal, offer non-invasive options Ethics committee review, focus on palliative care Communication Strategy Validate fears, emphasize quality of life Explain futility, use shared decision-making Comparing Both Scenarios

12. India’s legal position on these matters

13. Landmark Judicial Decisions Aruna Shanbaug Case (2011) : The Supreme Court allowed passive euthanasia under strict conditions . Common Cause Case (2018 ) : The Supreme Court, recognized the validity of advance medical directives, making it legal to withhold or withdraw life-sustaining treatment in certain cases.

14. Legal Framework Right to Life and Dignity (Article 21) The Indian Constitution guarantees the Right to Life under Article 21 , which includes the right to die with dignity . The Law Commission of India's 196th Report also addresses the withdrawal of life support, distinguishing between active euthanasia (illegal in India) and the withholding or withdrawal of futile medical interventions. The report emphasizes the importance of patient autonomy and the need for clear legal frameworks to guide end-of-life care decisions.

15. Guidelines by Medical Authorities The Indian Council of Medical Research (ICMR) has issued guidelines on end-of-life care, recognizing that futile treatment should not be continued unnecessarily . The National Medical Commission (NMC) follows ethical principles discouraging unnecessary prolongation of suffering.

16. Medical practitioners are advised to respect the decisions of competent patients regarding their treatment preferences . In cases where patients lack decision-making capacity, healthcare providers should consult with family members or legal surrogates and consider the patient's best interests while adhering to established legal and ethical guidelines . TAKE HOME MESSAGE

17. WHAT IN YOUR OPINION IS DIGNIFIED DEATH