During a recent audit, an observation stating that ceiling of care DNACPR should not be documented explicitly in the patient records was made.

In the first entry of our new series, focusing on the relationship between the contemporary palliatrist and the law, we focus on understanding decision making associated with treatment limitation.

Both treatment de-escalation and rationalization have been mentioned in relation to treatment limitation related decisions. The term de-escalation when the physician is uncertain of a withdrawal, offers the family de-escalation or non-escalation of curative interventions. A clear documentation of treatment related decisions at this point remains key.

Rationalization is used to describe treatment limitation documented at the time of transition of care from curative to palliative intent.

Though the Indian law does not distinguish between withholding and withdrawing treatment, it has been observed that physicians might prefer withholding rather than withdrawing treatment. This might be partly attributed to the lack of institutional policy safeguards on withdrawal of treatment which may be responsible for perpetuating this non-documentation of withdrawal, even though it is being practiced.

The use of nomenclature does not seem to provide any medicolegal protection to the practitioner. In the absence of a specific legislation, procedural compliance to the common cause framework, constitution and strict adherence to the findings of a primary and secondary medical board engineered process, family meetings documenting palliative care transition and shared decision making along with thorough note keeping might protect the physician from prosecution. Involvement of the Institutional legal counsel might be advised in complex cases.

There might be two co-existing realities in the Indian scenario, one where the patient’s families are forced to actively seek de-escalation after initial admission in the ICU upon refusal of intubation and Mechanical ventilation. The family’s preferences are then duly documented and death occurs in the ward with comfort measures instituted. On the other end of the divide, might be the patient who has been intubated and is on vasopressors and one who continues to receive them till the time of their death, because institutional practices for treatment withdrawal have not been set into motion.

A complex situation may arise when the physician preferences do not align with family’s values in an incapacitated patient. The Physician cannot accept the family’s refusal as the reason not to proceed with treatment escalation. The common cause framework would then provide a recourse for evidential record of treatment deliberation, family consultation and best interests decision making.

All of these merit the participation of a Palliatrist, but while the first offers a scenario where their involvement may be considered a matter of practice, the second and following scenarios require institution of frameworks and guidelines which advocate for their involvement.

References

Supreme Court of India. (2023). Common Cause (A Registered Society) v. Union of India, 2023 SCC OnLine SC 99. Supreme Court Reports.
Supreme Court of India. (2018). Common Cause (A Registered Society) v. Union of India, (2018) 5 SCC 1. Supreme Court Reports.
Indian Society of Critical Care Medicine & Indian Association of Palliative Care. (2024). Expert consensus and position statements for end-of-life and palliative care in the intensive care unit. Indian Journal of Critical Care Medicine, 28(3), 200–250. https://doi.org/10.5005/jp-journals-10071-24661

Cite as
Arora, R. D. (2026). Palliatrist and the Law 1 (PAL 1) – Legal aspects of treatment limitation. Zenodo. https://doi.org/10.5281/zenodo.21994324

Disclaimer

Every attempt has been made to safeguard the identity of patients referred to in the vignettes, and any untoward circumstances arising out of this academic treatise are completely unintended on the part of the author. The author does not intend to cause any harm to another individual’s or organisation’s reputation and has tried his level best to ensure that identities are fiercely protected.

Artificial intelligence tools, primarily Claude (Anthropic), have been employed for evidence synthesis and language refinement. They do not replace critical scholarship, clinical experience, or editorial judgment. Final responsibility for all interpretations, factual accuracy, originality of synthesis, and the quality of the published material rests entirely with the Founder and Editor.