06 Living Will/ Advanced Medical Directive (AMD)

Historical Evolution of the Right to Die with Dignity in India

1. Maruti Shripati Dubal vs. State of Maharashtra (1987) Cr.L.J. 549

   • Context: This Bombay High Court case involved a challenge to Section 309 of the Indian Penal Code (IPC), which criminalized attempted suicide.

   • Ruling: The court struck down Section 309, arguing that the right to life under Article 21 includes the right to die, thereby recognizing a limited form of autonomy over one’s life. The court viewed the criminalization of suicide as an infringement of personal liberty.

   • Significance: This was one of the earliest judicial acknowledgments of the right to die, though it was limited to the context of suicide rather than euthanasia or living wills.

2. Chenna Jagadeshwar vs. State of Andhra Pradesh (1988) Cr.L.J. 549

   • Context: This case revisited the issue of Section 309 IPC in the Andhra Pradesh High Court.

   • Ruling: Contrary to the Dubal judgment, the court upheld the constitutional validity of Section 309, arguing that the right to life does not inherently include the right to die.

   • Significance: This judgment highlighted a judicial divide on the interpretation of Article 21, setting the stage for further debate and clarification by higher courts.

3. P. Rathinam vs. Union of India (1994) 3 SCC 394

   • Context: A Supreme Court case challenging the constitutionality of Section 309 IPC.

   • Ruling: A two-judge bench ruled that the right to life under Article 21 includes the right not to live a forced life, effectively decriminalizing attempted suicide. The court reasoned that penalizing suicide was inhumane and inconsistent with personal autonomy.

   • Significance: This decision reinforced the idea that Article 21 encompasses both positive and negative aspects of the right to life, laying a philosophical foundation for the right to die with dignity.

4. Gian Kaur vs. State of Punjab (1996) 2 SCC 648

   • Context: This case arose when the Supreme Court reviewed the Rathinam decision in light of a constitutional bench referral.

   • Ruling: A five-judge bench overruled Rathinam, upholding the validity of Section 309 IPC. The court distinguished between suicide and euthanasia, stating that the right to life does not include the right to die unnaturally. However, it left room for euthanasia to be considered separately under specific circumstances.

   • Significance: While reversing the decriminalization of suicide, the judgment opened a nuanced discussion on euthanasia and dignified death, prompting further legal and legislative exploration.

5. Law Commission of India, 196th Report (2006): Medical Treatment of Terminally Ill Patients

   • Context: The Law Commission examined the legal framework for euthanasia and medical treatment of terminally ill patients.

   • Recommendations: It advocated for the legalization of passive euthanasia under strict safeguards and proposed protections for patients and medical practitioners. It also introduced the concept of advance directives (living wills) to allow individuals to express their end-of-life preferences.

   • Significance: This report influenced subsequent judicial and legislative developments by providing a structured framework for passive euthanasia and living wills.

6. Aruna Ramchandra Shanbaug vs. Union of India (2011) 2 SCR 869

   • Context: This landmark Supreme Court case involved Aruna Shanbaug, a nurse in a persistent vegetative state for decades. Her friend filed a plea for euthanasia.

   • Ruling: The court rejected active euthanasia (e.g., administering lethal drugs) but legalized passive euthanasia (withholding life-sustaining treatment) under strict guidelines. It allowed passive euthanasia to be sanctioned by High Courts after medical board approval. The court also recognized the validity of living wills in principle, though without detailed guidelines at the time.

   • Significance: This was the first judicial endorsement of passive euthanasia in India and a significant step toward recognizing the right to die with dignity under Article 21.

7. Law Commission of India, 241st Report (2012): Passive Euthanasia - A Relook

   • Context: A follow-up to the 196th Report and the Shanbaug judgment.

   • Recommendations: The Commission reiterated the need for a legal framework for passive euthanasia and living wills, refining earlier suggestions based on the Shanbaug ruling.

   • Significance: It kept the momentum alive for legislative action and provided further clarity on safeguards and procedures.

8. Common Cause vs. Union of India, W.P. (C) No. 215 of 2005 (2018)

   • Context: A public interest litigation by the NGO Common Cause sought recognition of the right to die with dignity and the enforceability of living wills.

   • Ruling: On March 9, 2018, a five-judge Constitution Bench of the Supreme Court recognized the right to die with dignity as an integral part of Article 21. The court legalized passive euthanasia and upheld the validity of living wills (Advance Medical Directives), allowing individuals to refuse life-sustaining treatment in cases of terminal illness or irreversible coma. Detailed guidelines were issued for the execution, authentication, and implementation of living wills, including oversight by medical boards and judicial authorities.

   • Significance: This judgment was a watershed moment, explicitly linking the right to die with dignity to constitutional protections and operationalizing living wills in India.

9. Mental Healthcare Act, 2017

   • Context: Enacted by Parliament, this law came into force in 2018.

   • Provisions: Section 5 allows adults to create advance directives specifying how they wish to be treated (or not treated) for mental illness, indirectly supporting the concept of autonomy in healthcare decisions.

   • Significance: While focused on mental health, it reinforced the legal acceptance of advance directives, complementing the Common Cause judgment.

10. Revised Guidelines on Advance Medical Directives (January 2023)

    • Context: Following practical challenges in implementing the 2018 Common Cause guidelines (e.g., bureaucratic delays, mandatory judicial oversight), the Supreme Court revisited the issue in 2023.

    • Ruling: On January 24, 2023, the Supreme Court simplified the process for executing and enforcing living wills. Key changes included removing the requirement for magistrate approval in some cases, allowing attestation by a notary or gazetted officer, and streamlining medical board procedures.

    • Significance: These guidelines made living wills more accessible and practical, ensuring that the right to die with dignity is not hindered by procedural complexities.

Summary of Legal Evolution

• Early Phase (1987-1996): Focused on the right to die in the context of suicide, with conflicting judicial views on Article 21’s scope.

• Middle Phase (2006-2011): Shifted toward euthanasia and end-of-life care, with the Law Commission and Shanbaug case laying the groundwork for passive euthanasia.

• Modern Phase (2012-2023): Culminated in the recognition of the right to die with dignity as a fundamental right under Article 21, with enforceable living wills and simplified guidelines.

Conclusion

The journey of the legal right to die with dignity in India reflects a progressive interpretation of Article 21, balancing individual autonomy with societal and ethical considerations. From the initial debate over suicide to the comprehensive framework for living wills in 2023, the Indian judiciary, supported by legislative efforts, has established a robust mechanism to ensure that terminally ill patients can exercise their right to a dignified death. The January 2023 guidelines mark the latest milestone, making this right more practical and accessible to the common citizen.

Common Cause Judgment of 2018 (link 1)

Background:

• Petitioner: The case was initiated by "Common Cause," a registered society advocating for good governance and citizens' rights, through a Public Interest Litigation (PIL) filed as Writ Petition (Civil) No. 215 of 2005.

• Objective: The petitioner sought a declaration that the "right to die with dignity" is an integral part of the "right to live with dignity" enshrined under Article 21 of the Indian Constitution, which guarantees the right to life and personal liberty.

Key Rulings (March 9, 2018):

1. Recognition of the Right to Die with Dignity:

   • A five-judge Constitution Bench of the Supreme Court, led by then Chief Justice Dipak Misra, unanimously held that the right to life under Article 21 includes the right to die with dignity. This encompasses the autonomy of individuals to refuse life-prolonging medical treatment in cases of terminal illness or irreversible coma.

   • The court emphasized that dignity in the process of dying is as fundamental as dignity in living, extending the scope of Article 21 beyond mere existence to a meaningful quality of life.

2. Legalization of Passive Euthanasia:

   • Building on the Aruna Shanbaug (2011) ruling, the court reaffirmed the legality of passive euthanasia—i.e., withholding or withdrawing life-sustaining treatment—under strict safeguards.

   • Active euthanasia (e.g., administering lethal drugs) remained prohibited.

3. Validation of Living Wills (Advance Medical Directives - AMD):

   • The court introduced and validated the concept of a living will, a written document in which a competent adult specifies their preferences regarding medical treatment in the event they become incapacitated and unable to communicate.

   • This was a groundbreaking step, as it allowed individuals to exercise autonomy over end-of-life decisions in advance.

4. Safeguarding Individual Autonomy:

   • The judgment underscored the principle of self-determination, ensuring that a person’s wishes regarding their body and medical treatment are respected, even when they can no longer express them.

   • It positioned living wills as a tool to protect this autonomy, aligning with global human rights standards.

5. Implementation Guidelines:

   • The court laid down a detailed, multi-tiered process for executing and enforcing living wills:

     • Execution: The living will must be in writing, signed by the maker in the presence of two attesting witnesses, and countersigned by a Judicial Magistrate of First Class (JMFC).

     • Authentication: The JMFC was required to verify and preserve the document, with copies sent to local authorities and family members.

     • Enforcement: When the individual becomes incapacitated, a medical board (comprising doctors) would assess the patient’s condition and the authenticity of the living will, followed by approval from the JMFC and a secondary medical board if needed.

   • This process was intended to prevent misuse and ensure informed decision-making.

Significance:

• The 2018 Common Cause judgment was a landmark in Indian constitutional law, formally recognizing living wills and passive euthanasia as extensions of fundamental rights. It laid the legal foundation for Advance Medical Directives in India, marking a shift toward patient-centric healthcare policies.

Problems with the 2018 Guidelines

Despite its progressive intent, the implementation framework established in 2018 faced significant practical challenges:

1. Highly Complex Process:

   • The requirement of multiple layers of oversight—two medical boards, a Judicial Magistrate, and local authorities—made the process cumbersome and bureaucratic.

   • Drafting a legally valid living will required technical precision, often necessitating legal assistance, which was inaccessible to many.

2. Time-Consuming:

   • The multi-tiered approval process, involving judicial and medical reviews, could take days or weeks, rendering it impractical in emergency medical situations where decisions need to be made swiftly.

   • Delays undermined the very purpose of a living will, which is to ensure timely respect for a patient’s wishes.

3. Impracticality:

   • The mandatory involvement of a JMFC for both execution and enforcement placed an undue burden on an already overstretched judicial system.

   • Rural and semi-urban populations, with limited access to magistrates or medical boards, found the process particularly unfeasible.

4. Lack of Awareness:

   • The judgment did not include mechanisms to educate the public or healthcare providers about living wills, limiting their adoption.

These issues led to criticism that while the judgment was theoretically sound, it was detached from ground realities, prompting calls for simplification.

Modifications in January 2023

Background:

• In response to the practical difficulties highlighted by stakeholders (including Common Cause and medical professionals), a petition was filed before the Supreme Court seeking clarification and modification of the 2018 guidelines.

• On January 24, 2023, a five-judge bench of the Supreme Court, headed by Justice K.M. Joseph, revisited the framework and issued revised guidelines.

Key Changes:

1. Simplified Execution Process:

   • The requirement of a Judicial Magistrate’s countersignature for creating a living will was removed. Instead, the document can now be attested by a notary public or a gazetted officer in the presence of two witnesses.

   • This reduced judicial involvement at the drafting stage, making it more accessible.

2. Streamlined Enforcement:

   • The earlier three-tiered process was simplified to a two-tiered system:

     • Primary Medical Board: A team of at least three doctors (including the treating physician) assesses the patient’s condition and the living will’s applicability.

     • Secondary Medical Board: A review board, constituted by the hospital or district Chief Medical Officer, confirms the decision if needed.

   • Judicial oversight (JMFC approval) is no longer mandatory unless there is a dispute (e.g., disagreement among family members or doctors).

3. Time-Bound Decisions:

   • The medical boards are required to decide within 48 hours, ensuring swift action in critical cases.

4. Storage and Accessibility:

   • Copies of the living will must be shared with the local government (e.g., municipal authorities) and stored digitally with a designated custodian (e.g., a family member or doctor), improving accessibility when needed.

5. Continued Flexibility:

   • The court reiterated that these guidelines are interim and will remain in force until Parliament enacts comprehensive legislation on living wills and passive euthanasia.

Significance of the 2023 Modifications:

• The revised guidelines addressed the core criticisms of complexity, delays, and inaccessibility, making living wills a more practical tool for exercising the right to die with dignity.

• By reducing bureaucratic hurdles and decentralizing authority (e.g., from magistrates to notaries), the court ensured broader reach and usability, especially for marginalized populations.

• The reaffirmation of the guidelines as a stopgap measure underscored the judiciary’s call for legislative action to provide a permanent statutory framework.

Conclusion

The Common Cause judgment of 2018 was a historic milestone that entrenched the right to die with dignity within the ambit of Article 21 and introduced living wills as a legal instrument in India. However, its initial guidelines were marred by procedural complexities that limited their real-world impact. The January 2023 modifications rectified these shortcomings, streamlining the process while preserving the core principles of autonomy and dignity. Until a dedicated law is enacted, these revised guidelines serve as a pragmatic bridge, ensuring that the right to die with dignity is not just a theoretical promise but a functional reality for Indian citizens.

Advance Care Planning (ACP)

Definition:

• Advance Care Planning (ACP) is a voluntary process that enables individuals with mental capacity to make decisions and communicate their preferences about future healthcare, particularly for situations where they may lose the ability to make or express choices (e.g., terminal illness, coma, or severe cognitive impairment).

• It involves discussions with family, healthcare providers, and sometimes legal professionals to ensure that an individual’s values, beliefs, and wishes guide their medical treatment.

Purpose:

• To promote autonomy and ensure that healthcare decisions align with a person’s desires, even when they cannot speak for themselves.

• To reduce uncertainty and conflict for families and medical professionals during critical situations.

Main Components of ACP

ACP typically includes the following key elements, which may vary by jurisdiction but are universally recognized in principle:

1. Advance Care Directive (ACD):

   • A broad term encompassing legal instructions or documents that outline an individual’s healthcare preferences for future medical scenarios.

   • It serves as an umbrella category that includes specific tools like living wills and medical power of attorney.

   • In India, the Supreme Court’s Common Cause (2018) judgment and its 2023 modifications use the term Advance Medical Directive (AMD) interchangeably with ACD to refer to living wills specifically.

2. Living Will:

   • A written document in which a competent individual specifies their preferences regarding medical interventions, particularly life-sustaining treatments (e.g., ventilators, feeding tubes), in the event of terminal illness or irreversible incapacity.

   • It focuses on what treatments the person does not want, rather than appointing someone to decide.

   • In India: The living will was formalized under the 2018 Common Cause judgment, allowing individuals to refuse life-prolonging treatment under strict guidelines (simplified in 2023).

3. Medical Power of Attorney (Health Care Power of Attorney - POA):

   • A legal document appointing a trusted person (called a proxy, surrogate, or attorney-in-fact) to make healthcare decisions on behalf of the individual if they become incapacitated.

   • Unlike a living will, which specifies treatment preferences, a medical POA delegates decision-making authority to another person based on the individual’s known values or best interests.

   • In India: While not explicitly detailed in the Common Cause judgment, the concept aligns with the broader framework of ACP and could be implemented under general power of attorney laws (e.g., Powers of Attorney Act, 1882), though it lacks specific statutory backing for healthcare decisions as of now.

Advance Directive (AD): A Broader Category

• Definition: An advance directive (AD) is a legal instrument that records an individual’s healthcare wishes to guide medical professionals and loved ones when the person cannot communicate. It is a generic term that encompasses various documents depending on the context.

• Purpose: To ensure that medical care reflects the individual’s preferences, reducing unwanted interventions and honoring autonomy.

Common Types of Advance Directives:

1. Living Will:

   • As described above, it outlines specific treatment preferences (e.g., refusal of artificial life support).

2. Medical Power of Attorney:

   • As described above, it designates a decision-maker.

3. Physician Orders for Life-Sustaining Treatment (POLST):

   • A medical order signed by a physician, based on a patient’s preferences, specifying treatments to be provided or withheld in emergencies (e.g., CPR, intubation).

   • Typically used for seriously ill or frail patients with a limited life expectancy.

   • Not applicable in India: POLST is specific to certain U.S. states and requires a structured healthcare system with portable medical orders, which India lacks as of now.

4. Medical Orders for Life-Sustaining Treatment (MOLST):

   • Similar to POLST, but a variant used in specific regions (e.g., New York). It translates patient wishes into actionable medical orders.

   • Not applicable in India: Like POLST, it is jurisdiction-specific and not part of the Indian framework.

5. Transportable Physician Orders for Patient Preferences (TPOPP):

   • Another U.S.-based variant of POLST, emphasizing portability across healthcare settings.

   • Not applicable in India: No equivalent exists in the Indian legal or medical system.

Note: In India, the term "Advance Directive" is most closely associated with the living will as per the Supreme Court’s rulings. Concepts like POLST, MOLST, and TPOPP are not currently part of the Indian healthcare system, which relies on judicial guidelines rather than physician-driven medical orders.

ACP in the Indian Context

Legal Foundation:

• The Common Cause vs. Union of India (2018) judgment, as modified in January 2023, is the cornerstone of ACP in India. It focuses primarily on the living will as the operative advance directive, validated under Article 21’s right to die with dignity.

• The 2018 ruling introduced a framework for AMDs, requiring execution in the presence of witnesses and a Judicial Magistrate (later simplified in 2023 to involve a notary or gazetted officer).

• The Mental Healthcare Act, 2017 also supports ACP by allowing advance directives for mental health treatment (Section 5), though this is narrower in scope.

Current Components in India:

1. Living Will:

   • Recognized and operationalized with specific guidelines (e.g., attestation by two witnesses and a notary, medical board oversight).

2. Medical Power of Attorney:

   • Not explicitly regulated under the 2018 or 2023 guidelines for end-of-life care. However, a general power of attorney could theoretically be used to appoint a healthcare proxy, though its enforceability in medical contexts remains untested in Indian courts.

3. Advance Care Directive:

   • In practice, this is synonymous with the living will in India, as no broader statutory framework exists to include other forms like POLST.

Challenges in India:

• Lack of a comprehensive legislative framework: The Supreme Court guidelines are interim, pending parliamentary action.

• Limited public awareness and infrastructure: Many Indians are unaware of ACP, and rural areas lack access to notaries, medical boards, or legal support.

• Absence of physician-driven orders: Unlike POLST/MOLST, India’s system relies on patient-initiated documents and judicial/medical oversight rather than portable medical orders.

Comparison: Living Will vs. Medical Power of Attorney

Aspect Living Will Medical Power of Attorney

Purpose Specifies treatment preferences Appoints a decision-maker

Scope Limited to instructions in the document Broader, allows proxy to interpret wishes

Legal Status in India Recognized (Common Cause, 2018/2023) Not explicitly regulated for healthcare

Execution Written, witnessed, notarized (India, 2023) General POA possible, but not specific

Flexibility Fixed unless revoked Proxy can adapt to unforeseen situations

Conclusion

Advance Care Planning (ACP) is a critical process for ensuring autonomy in healthcare decisions, with advance directives like living wills and medical power of attorney as its core tools. In India, ACP is primarily anchored in the living will, validated by the Common Cause judgment (2018) and made more practical in 2023. While the medical power of attorney exists conceptually, it lacks specific legal recognition in the end-of-life context. Forms like POLST, MOLST, and TPOPP, common in places like the U.S., are absent in India due to differences in healthcare and legal systems. For ACP to fully flourish in India, legislative action is needed to integrate these components into a cohesive, accessible framework, as the Supreme Court has repeatedly emphasized. Until then, the living will remains the most prominent and legally supported element of ACP in the country.

Living Will

Definition:

• A Living Will is a written legal document in which an individual outlines their healthcare wishes for end-of-life care, to be followed if they become terminally ill, permanently unconscious, or otherwise unable to make or communicate decisions due to incapacity.

Purpose:

• To ensure that a person’s preferences regarding medical treatment (or refusal thereof) are respected when they can no longer express them.

• It provides clarity to healthcare providers and family members, reducing ambiguity and emotional burden during critical situations.

Key Features:

• Scope: Focuses on end-of-life care, particularly the refusal of life-sustaining treatments (e.g., ventilators, artificial nutrition, resuscitation).

• Content: Specifies the type and level of medical care desired, such as:

  • Whether to initiate or continue life-prolonging measures.

  • Conditions under which treatment should be withheld (e.g., terminal illness, irreversible coma).

  • Preferences for palliative care or comfort measures over aggressive interventions.

• Execution: Must be created when the individual has mental capacity and is competent to understand the implications.

Legal Status in India:

• Recognized under the Common Cause vs. Union of India (2018) judgment as an Advance Medical Directive (AMD), upheld as part of the right to die with dignity under Article 21 of the Indian Constitution.

• 2018 Guidelines: Required execution in writing, signed by the maker, with two witnesses and countersignature by a Judicial Magistrate of First Class (JMFC).

• 2023 Modifications: Simplified to require only two attesting witnesses and attestation by a notary public or gazetted officer, removing mandatory JMFC involvement unless disputes arise.

• Enforcement: When the individual becomes incapacitated, a primary medical board assesses the condition and living will, with a secondary board confirming if needed, ensuring decisions align with the document.

Example Scenario:

• A person writes a living will stating, “If I am terminally ill with no hope of recovery, I refuse mechanical ventilation and tube feeding, preferring only pain management.” If they later fall into a coma, doctors follow these instructions after medical board approval.

Medical Power of Attorney (Health Care Power of Attorney)

Definition:

• A Medical Power of Attorney (POA) is a legal document that allows a person to designate another individual (known as a proxy, surrogate, or attorney-in-fact) as their healthcare decision-maker. This proxy makes healthcare decisions on behalf of the person if they lose the capacity to do so.

Purpose:

• To delegate authority to a trusted individual to interpret and implement healthcare decisions based on the person’s values, wishes, or best interests when they are incapacitated.

• Offers flexibility for unforeseen medical situations not covered by a living will.

Key Features:

• Scope: Covers a broader range of healthcare decisions, not limited to end-of-life care, including treatments, surgeries, or long-term care options.

• Content: Specifies:

  • The identity of the appointed proxy (e.g., a spouse, sibling, or friend).

  • The extent of decision-making authority (e.g., all healthcare decisions or specific categories).

  • Optional guidance on the person’s values or preferences to inform the proxy’s choices.

• Execution: Must be created while the individual has mental capacity, typically formalized in writing and witnessed or notarized, depending on jurisdiction.

Legal Status in India:

• Not Explicitly Regulated for Healthcare: Unlike the living will, the medical power of attorney is not specifically addressed in the Common Cause (2018) judgment or its 2023 updates for end-of-life care.

• General Power of Attorney: Under the Powers of Attorney Act, 1882, a person can appoint an attorney-in-fact for various matters, potentially including healthcare decisions. However, its enforceability in medical contexts lacks clear judicial or statutory backing in India as of March 2025.

• Mental Healthcare Act, 2017: Section 4 allows for a “nominated representative” to make mental health treatment decisions, which is akin to a limited medical POA, but this does not extend to general healthcare or end-of-life scenarios.

• Potential Use: In practice, a general POA could be drafted to include healthcare decision-making, but its legal weight in overriding medical or family objections remains untested in Indian courts.

Example Scenario:

• A person appoints their daughter as their medical POA. If they suffer a stroke and cannot communicate, the daughter decides whether to approve surgery or shift to palliative care, guided by prior discussions or the person’s known wishes.

Comparison: Living Will vs. Medical Power of Attorney

Aspect Living Will Medical Power of Attorney

Nature Directive (specific instructions) Delegation (appoints a decision-maker)

Focus End-of-life care preferences Broader healthcare decisions

Decision-Maker Pre-determined by the document Proxy interprets and decides

Flexibility Limited to what’s written; no adaptation Proxy can adapt to new circumstances

Legal Status in India Explicitly recognized (2018/2023 rulings) Not specifically regulated for healthcare

Execution in India Written, witnessed, notarized (2023) Possible via general POA, but unclear

Enforcement Medical boards follow instructions Proxy acts; enforceability uncertain

Integration in Advance Care Planning (ACP)

• Complementary Roles: A living will and medical POA are often used together in robust ACP systems (e.g., in the U.S.). The living will provides specific instructions, while the POA covers gaps or situations requiring interpretation.

• India’s Context: As of March 2025, India’s ACP framework heavily favors the living will due to its judicial recognition. The absence of a clear medical POA mechanism limits the flexibility of ACP, leaving families or doctors to make decisions in unaddressed scenarios, potentially conflicting with patient autonomy.

Practical Implications in India

1. Living Will:

   • Strengths: Legally binding, clear guidelines, and simplified execution (post-2023) make it accessible for refusing unwanted treatments.

   • Limitations: Static nature means it cannot address every medical scenario, and revocation requires capacity, which may be lost.

2. Medical Power of Attorney:

   • Strengths: Offers dynamic decision-making through a trusted proxy, ideal for complex or evolving health conditions.

   • Limitations: Lack of specific legal recognition in India creates uncertainty, and proxies may face resistance from family or medical professionals without statutory backing.

Current Gap: Without legislation integrating both tools, India’s ACP system remains incomplete. The Supreme Court’s 2023 reiteration that its guidelines are interim underscores the need for a comprehensive law to formalize both living wills and medical POAs.

Conclusion

A Living Will is a proactive document that locks in an individual’s end-of-life care preferences, legally enforceable in India since 2018 and streamlined in 2023. A Medical Power of Attorney, while conceptually valuable for delegating healthcare decisions, lacks a dedicated legal framework in India, relying on general POA provisions with uncertain enforceability. Together, they form the backbone of ACP in theory, but India’s current system prioritizes the living will. For a fully functional ACP regime, legislative action is essential to clarify and integrate the medical POA, ensuring that both autonomy (via living wills) and flexibility (via proxies) are safeguarded. Until then, the living will remains the primary tool for Indians to assert their healthcare wishes at life’s end.

Definitions and Overview

• Advance Directive: A broad term for a legal document that outlines a person’s wishes regarding medical treatment if they become incapacitated or unable to communicate. It ensures that healthcare decisions align with their preferences when they can’t speak for themselves. According to Black’s Law Dictionary (as you referenced), it’s “a legal document explaining one’s wishes about medical treatment if one becomes incompetent or unable to communicate.”

• Living Will: A specific type of advance directive. It focuses solely on detailing the kinds of medical treatments a person does or does not want (e.g., life support, resuscitation, feeding tubes) in specific situations, typically terminal illness or permanent unconsciousness.

In short: All living wills are advance directives, but not all advance directives are living wills. An advance directive is the umbrella term, while a living will is one component under it.

Types of Advance Directives

Advance directives can include several elements, depending on jurisdiction and individual needs:

1. Living Will: Specifies medical treatment preferences (e.g., “No ventilator if I’m in a persistent vegetative state”).

2. Medical Power of Attorney (or Durable Power of Attorney for Healthcare): Designates a trusted person (an agent or proxy) to make healthcare decisions on your behalf if you’re incapacitated. Unlike a living will, it covers a broader range of decisions beyond just end-of-life care.

3. Healthcare Proxy: Similar to a medical power of attorney, this is the individual named to act on your behalf. The term is sometimes used interchangeably with the document appointing them.

Key Differences

Aspect Living Will Advance Directive (General)

Scope Specific instructions for treatment Broader, may include instructions and/or proxy appointment

Focus End-of-life or critical care preferences Can cover any healthcare scenario

Decision Maker No one—directly guides doctors May appoint a proxy to decide

Flexibility Limited to what’s written Proxy can adapt to unforeseen situations

Legislation Context: The Mental Healthcare Act, 2017 (India)

You mentioned The Mental Healthcare Act, 2017, which is relevant in India. This law introduced the concept of an Advance Directive for mental health treatment, allowing individuals to specify how they wish to be treated (or not treated) for mental illness if they lose capacity. It also allows for a Nominated Representative—akin to a healthcare proxy—who can make decisions if the person becomes incompetent. This aligns with the broader concept of advance directives but is specific to mental healthcare. Unlike a living will, which typically focuses on physical end-of-life care (e.g., ventilators), this applies to psychiatric treatment (e.g., medication or hospitalization preferences).

Note: In India, living wills were separately recognized by the Supreme Court in 2018, allowing passive euthanasia under strict guidelines, but they aren’t directly governed by the Mental Healthcare Act.

Summary

• A Living Will is a subset of an Advance Directive, focusing on specific medical treatment wishes.

• An Advance Directive can also include a Medical Power of Attorney or Healthcare Proxy to appoint someone to decide for you.

• In the context of The Mental Healthcare Act, 2017, advance directives extend to mental health, with a nominated representative acting similarly to a proxy.

If you’d like me to dig deeper into any specific part—like the Act, proxy roles, or jurisdictional differences—just let me know!

A Living Will is a critical document that ensures your healthcare preferences are respected when you can no longer communicate them, particularly in end-of-life situations. Based on your input and the legal framework in India (as shaped by the Common Cause vs. Union of India (2018) judgment and its 2023 modifications), here’s a detailed guide on what a living will should contain. The content should be clear, specific, and tailored to your values and wishes, while adhering to the legal requirements for enforceability in India as of March 5, 2025.

What Should a Living Will Contain?

A living will should comprehensively outline your preferences for medical treatment and care in scenarios where you are terminally ill, in a persistent vegetative state, or otherwise incapacitated. Below are the key elements to include, based on your suggestions and standard practices:

1. Personal Identification

• Full Name, Address, and Date of Birth: To ensure the document is unmistakably linked to you.

• Statement of Capacity: A declaration that you are of sound mind and legal age (above 18) at the time of drafting, as mental capacity is a prerequisite for validity.

2. Nature of Treatment You Would Like to Receive

• Specify the type and level of medical care you consent to, particularly for end-of-life situations:

  • Palliative Care: Indicate if you want treatments focused on pain relief and comfort (e.g., medication for pain or symptom management).

  • Specific Interventions: Mention any treatments you explicitly desire, such as antibiotics for infections or oxygen support, if applicable.

  • Conditions: Clarify the circumstances under which these treatments should apply (e.g., “only if there’s a reasonable chance of recovery”).

3. Supports and Treatments You Would Like or Prefer Not to Have

• This is the core of a living will, detailing what you do not want when terminally ill or irreversibly incapacitated. Be specific to avoid ambiguity:

  • Hospitalization: State whether you consent to being admitted to a hospital or prefer to avoid it (e.g., “I do not wish to be hospitalized unless necessary for comfort care”).

  • ICU Admission: Indicate your stance on intensive care unit admission (e.g., “I refuse ICU admission if my condition is terminal”).

  • Resuscitation and Life-Sustaining Measures:

    • Do Not Resuscitate (DNR): Specify if you refuse cardiopulmonary resuscitation (CPR), chest compression, or defibrillation (e.g., “I do not want resuscitation if my heart stops”).

    • Mechanical Ventilation: Clarify whether you want to be placed on a ventilator (e.g., “I refuse mechanical ventilation if recovery is unlikely”).

  • Invasive Tubes: Address preferences for procedures like intubation or catheters (e.g., “I do not want invasive tubes unless they improve my comfort”).

  • Feeding Tubes: State your position on artificial nutrition (e.g., “I refuse feeding tubes if I am in a persistent vegetative state”).

  • Artificial Hydration and Nutrition: Specify if you want IV fluids or tube feeding withheld (e.g., “I decline artificial hydration if my condition is irreversible”).

4. Preferred Place of Care and Death

• Indicate where you wish to receive care and pass away:

  • Home: “I prefer to remain at home with palliative care, if possible.”

  • Hospital: “I consent to hospital care only for symptom management.”

  • Hospice: “I wish to be moved to a hospice facility for end-of-life care.”

• This helps guide family and healthcare providers on your environmental preferences.

5. Conditions Triggering the Living Will

• Define the medical scenarios in which your instructions apply:

  • Terminal Illness: “If diagnosed with a terminal condition with no reasonable hope of recovery.”

  • Persistent Vegetative State: “If I am in an irreversible coma or vegetative state for [specify duration, e.g., 30 days].”

  • Incapacity: “If I am unable to communicate or make decisions due to severe illness or injury.”

6. Revocation Clause

• Include a statement allowing you to revoke or amend the living will while you retain capacity (e.g., “I reserve the right to revoke this document in writing or orally, if competent”).

• This ensures flexibility if your preferences change.

7. Additional Instructions (Optional)

• Religious or Personal Beliefs: Mention if your choices are guided by faith or values (e.g., “My decisions align with [specific belief system]”).

• Organ Donation: Indicate if you consent to organ donation after death (e.g., “I wish to donate my organs if medically feasible”).

• Funeral Preferences: While not legally binding in a living will, some include wishes for after death (e.g., “I prefer cremation over burial”).

8. Legal Requirements (India-Specific)

• Execution Details: Per the 2023 Supreme Court guidelines:

  • Signed by you in the presence of two attesting witnesses (who are independent and not beneficiaries).

  • Attested by a notary public or gazetted officer.

• Distribution: Specify that copies should be given to family, your doctor, and a designated custodian (e.g., local government authority or hospital), as required in India.

Sample Living Will Template (Simplified for India)

Below is an example of what a living will might look like, incorporating the above elements:

LIVING WILL OF [Your Full Name]

Date: [Insert Date]

I, [Full Name], residing at [Address], born on [Date of Birth], being of sound mind and above 18 years of age, hereby declare my healthcare wishes for situations where I am unable to communicate due to terminal illness, persistent vegetative state, or irreversible incapacity.

1. Medical Treatment Preferences:

   • I consent to palliative care for pain relief and comfort but refuse life-sustaining treatments if my condition is terminal or recovery is unlikely.

   • I do not wish to be hospitalized or admitted to the ICU unless it enhances my comfort.

   • I refuse resuscitation (CPR), chest compression, mechanical ventilation, invasive tubes, feeding tubes, and artificial hydration/nutrition if I am in an irreversible condition.

2. Preferred Place of Care:

   • I prefer to receive care and pass away at my home, [Address], with palliative support, unless medical necessity requires otherwise.

3. Conditions:

   • These instructions apply if I am diagnosed with a terminal illness with no hope of recovery or remain in a vegetative state for more than 30 days, as certified by a medical board.

4. Revocation:

   • I may revoke or amend this living will in writing or orally while I retain mental capacity.

I execute this document voluntarily and request that my healthcare providers and family honor these wishes.

Signed: _________________________

[Your Signature]

Date: _________________________

Witnesses:

1. Name: _________________________
   Signature: _____________________
   Address: ______________________

2. Name: _________________________
   Signature: _____________________
   Address: ______________________

Attestation:

Attested by: [Notary Public/Gazetted Officer Name]

Signature: _____________________

Date: _________________________

Tips for Drafting a Living Will

1. Be Specific: Vague terms like “no heroic measures” can lead to misinterpretation. Use clear language about treatments and conditions.

2. Consult Professionals: Discuss with a doctor to understand medical terms and scenarios, and a lawyer or notary to ensure compliance with Indian law.

3. Communicate: Share your living will with family and doctors to avoid surprises or disputes.

4. Review Periodically: Update it if your health or preferences change, ensuring it reflects your current wishes.

Legal Considerations in India (March 2025)

• Enforceability: The Supreme Court’s 2023 guidelines ensure that a properly executed living will is binding on medical professionals, subject to medical board approval.

• Safeguards: The process involves a primary and secondary medical board to verify the patient’s condition and the document’s authenticity, protecting against misuse.

• Pending Legislation: These guidelines are interim until Parliament enacts a law, so staying updated on legal changes is advisable.

Conclusion

A living will should clearly articulate your preferences for end-of-life care, including the nature of treatments you want or refuse (e.g., resuscitation, ventilation, feeding tubes), your preferred place of care (home or hospital), and the conditions under which these apply. In India, it must be written, witnessed, and notarized per the 2023 guidelines to be legally valid. By including these elements, you ensure your autonomy is respected, aligning with the right to die with dignity under Article 21. 

When Does a Living Will Come into Effect?

A Living Will does not take effect immediately upon its creation. It is a prospective document designed to guide healthcare decisions only under specific circumstances when the person who made it (the "maker") can no longer exercise their decision-making capacity. Here’s when and how it comes into play:

1. Triggering Condition: Incapacity to Make or Communicate Decisions

• A Living Will comes into effect only when the person making it is unable to make or communicate healthcare decisions for themselves. This typically occurs in the following situations:

  • Terminal Illness: The maker is diagnosed with an incurable condition with no reasonable hope of recovery, rendering them incapable of decision-making.

  • Persistent Vegetative State (PVS): The maker is in an irreversible coma or unconscious state, unable to interact with their environment or express preferences.

  • Severe Cognitive Impairment: Conditions like advanced dementia or brain injury prevent the maker from understanding or communicating choices.

  • Critical Medical Emergency: A sudden event (e.g., stroke, cardiac arrest) leaves the maker incapacitated.

• Key Requirement: The incapacity must be medically verified. In India, this is determined by a medical board, not just the attending doctor, to ensure objectivity.

2. Timing of Activation

• The Living Will remains dormant as long as the maker retains mental capacity and can communicate their wishes directly (verbally or otherwise). It activates only when:

  • The maker’s condition matches the scenarios outlined in the document (e.g., “if I am terminally ill” or “if I am in a vegetative state for 30 days”).

  • The maker is no longer competent to consent to or refuse treatment in real-time.

3. Process After Activation (India-Specific)

Once the maker is deemed incapacitated, the healthcare provider refers to the Living Will to guide treatment decisions. The process in India, as per the 2023 Supreme Court guidelines, involves the following steps:

• Referral to the Living Will:

  • The healthcare provider (e.g., doctor or hospital) reviews the wishes and refusals stated in the document. For example:

    • Refusal of mechanical ventilation, feeding tubes, or resuscitation.

    • Preference for palliative care over aggressive treatment.

  • The document serves as the primary source of the maker’s intent.

• Medical Board Assessment:

  • Primary Medical Board: A team of at least three doctors (including the treating physician) evaluates:

    • The maker’s current medical condition (e.g., terminal, irreversible).

    • Whether the situation aligns with the conditions specified in the Living Will.

    • The authenticity and applicability of the document.

  • Secondary Medical Board: If required (e.g., for confirmation or in complex cases), a review board, appointed by the hospital or district Chief Medical Officer, re-assesses the case.

  • Timeframe: Boards must decide within 48 hours to ensure timely action.

• Consultation with a Healthcare Proxy (If Applicable):

  • In India, the Living Will itself does not legally designate a healthcare proxy (unlike a Medical Power of Attorney, which isn’t explicitly regulated for end-of-life care). However:

    • If the maker informally named a contact person or custodian in the Living Will (e.g., a family member to hold a copy), the healthcare provider may consult them for clarification or context.

    • If a separate Medical Power of Attorney exists under general law (e.g., Powers of Attorney Act, 1882), the proxy’s role might come into play, though its enforceability in healthcare decisions remains untested in India.

  • The Living Will’s instructions take precedence over proxy input unless the document explicitly allows the proxy to interpret or override it (not standard in India’s framework).

• Execution of Wishes:

  • After board approval, the healthcare provider implements the maker’s stated preferences (e.g., withholding life-sustaining treatment or shifting to palliative care).

  • If disputes arise (e.g., family objections), the matter may escalate to a Judicial Magistrate of First Class (JMFC), though this is rare under the simplified 2023 process.

4. Exceptions and Limitations

• Revocation: The Living Will has no effect if the maker revokes it while still competent (in writing or orally, as specified in the document).

• Ambiguity: If the document is unclear or does not cover the specific medical scenario, healthcare providers may default to standard medical practice or consult family, subject to ethical and legal norms.

• Legal Compliance: Treatments cannot violate Indian law (e.g., active euthanasia remains illegal, so a request for lethal injection would be unenforceable).

Example Scenario

• Living Will Content: “If I am terminally ill with no hope of recovery or in a vegetative state for over 30 days, I refuse mechanical ventilation, feeding tubes, and resuscitation, and prefer palliative care at home.”

• Situation: The maker suffers a massive stroke, falls into a coma, and after 30 days, doctors confirm no recovery is possible.

• Effect:

  • The hospital confirms incapacity via a primary medical board.

  • The board reviews the Living Will, verifies the coma duration exceeds 30 days, and approves withholding ventilation and feeding tubes.

  • A secondary board confirms within 48 hours.

  • The patient is shifted to palliative care, ideally at home if feasible, per the document.

Key Points in India (March 2025)

• Activation Trigger: Only when the maker cannot make or communicate decisions, as certified by a medical board.

• Role of Healthcare Provider: Refers to the Living Will and follows its directives after board approval.

• Proxy Involvement: Limited unless a separate Medical Power of Attorney exists (not part of the Living Will framework in India).

• Legal Framework: Governed by the 2023 Supreme Court guidelines, requiring medical board oversight rather than unilateral doctor or proxy decisions.

Conclusion

A Living Will comes into effect only when the person who made it is unable to make or communicate healthcare decisions, such as in cases of terminal illness or irreversible incapacity. At that point, healthcare providers in India refer to the document’s stated wishes and refusals, validated by a two-tier medical board process within 48 hours. While a healthcare proxy may be consulted informally (or via a separate POA), the Living Will’s instructions are paramount under the current legal framework. This ensures the maker’s autonomy is upheld precisely when they can no longer speak for themselves, aligning with the right to die with dignity under Article 21.

Why a Living Will Matters: The Benefits

A Living Will is more than a legal document—it’s a tool that safeguards your autonomy, reduces uncertainty, and aligns medical care with your values, especially during vulnerable end-of-life situations. Here are the key benefits:

1. Opportunity to Reflect and Plan

• Benefit: Provides you the opportunity to think about, talk about, and write down your preferences and refusals for medical treatment.

• Why It Matters:

  • End-of-life scenarios can be emotionally and medically complex. A Living Will encourages proactive reflection on what matters to you—whether it’s comfort, dignity, or avoiding prolonged suffering—before a crisis occurs.

  • It prompts discussions with family, friends, or doctors, ensuring your wishes are understood and reducing the likelihood of misinterpretation later.

  • Writing them down creates a clear, legally recognized record, preventing reliance on vague verbal statements or assumptions.

• Example: You might decide you value quality of life over quantity and refuse invasive treatments like ventilators, opting instead for palliative care. Documenting this ensures your perspective guides your care.

2. Empowerment to Make Your Own Decisions

• Benefit: Allows you to make your own decisions on how you would like to be cared for and what treatments you prefer to have or not have toward the end of life, especially when you are unable to make decisions or communicate.

• Why It Matters:

  • Without a Living Will, decisions may fall to family members or doctors who might not know your preferences, potentially leading to unwanted interventions (e.g., prolonged life support) or neglect of your comfort.

  • It ensures your voice remains central, even when you’re incapacitated due to terminal illness, coma, or severe impairment.

  • In India, this aligns with the constitutional right to die with dignity under Article 21, as recognized in the Common Cause judgment, reinforcing your autonomy over your body and medical fate.

• Example: If you specify, “I refuse feeding tubes if I’m in a vegetative state,” doctors must honor that, preventing a scenario where you’re kept alive artificially against your wishes.

3. Control Over End-of-Life Care

• Benefit: Gives you control over the type and level of care you receive, including specific refusals (e.g., ICU admission, resuscitation) and preferences (e.g., home care).

• Why It Matters:

  • End-of-life care often involves aggressive treatments that may extend life but compromise comfort or dignity. A Living Will lets you opt out of such measures if they don’t align with your values.

  • You can dictate your preferred place of care (e.g., home vs. hospital), ensuring your final days reflect your personal vision of dignity.

  • It reduces the risk of over-treatment, which can be physically taxing and financially draining for families.

• Example: Stating, “I want to die at home with palliative care, not in an ICU,” ensures your care team prioritizes your comfort and location preferences.

4. Reduces Burden on Family and Loved Ones

• Benefit: Relieves family members of the emotional and ethical burden of guessing your wishes or making tough decisions on your behalf.

• Why It Matters:

  • Without clear guidance, loved ones may face guilt, conflict, or disagreement over whether to continue life support or let go. A Living Will spares them this anguish by providing explicit instructions.

  • It minimizes disputes among family members with differing views, as your written preferences carry legal weight in India (post-2023 guidelines).

• Example: If your family is torn between prolonging your life via machines or letting nature take its course, your Living Will saying “No mechanical ventilation” resolves the dilemma.

5. Ensures Dignity and Peace of Mind

• Benefit: Protects your dignity by aligning medical care with your values and offers peace of mind knowing your wishes will be respected.

• Why It Matters:

  • For many, dignity means avoiding futile treatments or prolonged suffering. A Living Will ensures you’re not subjected to interventions you deem undignified.

  • Knowing your preferences are documented provides reassurance to you and your loved ones, reducing anxiety about the unknown.

• Example: Refusing artificial nutrition in a terminal state ensures you’re not sustained in a way you find dehumanizing, preserving your sense of self.

6. Legal Clarity and Enforceability (India-Specific)

• Benefit: In India, a Living Will is legally binding under the Supreme Court’s 2023 guidelines, ensuring healthcare providers follow your directives.

• Why It Matters:

  • The structured process (medical board approval within 48 hours) guarantees your wishes aren’t ignored or overridden without cause.

  • It bridges the gap when you can’t advocate for yourself, making your refusals (e.g., “no resuscitation”) actionable rather than aspirational.

• Example: A hospital can’t force ICU admission if your Living Will explicitly refuses it, as the medical board must comply post-verification.

How It Works in Practice (India, March 2025)

• When It Activates: The Living Will takes effect only when you’re incapacitated (e.g., terminally ill, in a coma), as certified by a primary medical board.

• Process: Doctors refer to your documented wishes, a secondary board confirms if needed, and your care aligns with your instructions (e.g., shifting to palliative care instead of ventilation).

• Outcome: Your preferences—whether to receive comfort care or refuse invasive procedures—are executed, honoring your autonomy.

Broader Implications

• Personal Empowerment: You retain control over your body and destiny, a right upheld by Article 21 in India.

• Societal Benefit: Encourages a cultural shift toward open conversations about death and dying, destigmatizing end-of-life planning.

• Healthcare Efficiency: Reduces unnecessary treatments, easing the strain on medical resources and costs.

Conclusion

A Living Will matters because it transforms your healthcare preferences and refusals from abstract thoughts into actionable directives, ensuring you’re cared for on your terms when you can’t speak for yourself. It offers the chance to reflect, decide, and document your wishes—whether that’s refusing resuscitation or choosing home care—sparing your family from guesswork and preserving your dignity. In India, its legal backing since 2018 (refined in 2023) makes it a powerful tool for autonomy, providing peace of mind and clarity in life’s final chapter. 

Procedure to Record and Preserve an Advance Directive

Recording and preserving an Advance Directive involves creating a legally valid document and ensuring it is stored and accessible when needed. This process was outlined in Common Cause (2018) and refined in 2023 to make it more practical. Below are the steps and requirements:

1. Signature and Attestation

• Source: Para 198.3.1 of Common Cause (2018), modified in 2023.

• Requirements:

  • Signed by the Executor: The individual creating the Advance Directive must sign it.

  • Witnesses: Signed in the presence of two attesting witnesses, preferably independent (not family members, beneficiaries, or healthcare providers involved in the executor’s care).

  • Attestation:

    • Originally (2018): Required countersignature by a Judicial Magistrate of the First Class (JMFC).

    • Modified (2023): Now attested before a notary public or gazetted officer, simplifying the process.

• Purpose: Ensures authenticity and protects against fraud or coercion.

2. Recording Satisfaction of Execution and Capacity

• Source: Para 198.3.7 of Common Cause (2018).

• Requirements:

  • The witnesses and the notary or gazetted officer must record their satisfaction that:

    • The document was executed voluntarily, without coercion, inducement, or compulsion.

    • The executor had full understanding of the relevant information and consequences (e.g., that withholding treatment may lead to death).

  • Example Statement: “We confirm that [Executor’s Name] executed this Advance Directive willingly and with comprehension of its implications.”

• Purpose: Verifies the executor’s mental capacity and intent, aligning with informed consent principles.

3. Handover to Custodian

• Source: Para 198.3.6 of Common Cause (2018), modified in 2023.

• Requirements:

  • The Advance Directive shall be handed over to a designated custodian, typically:

    • An official nominated by the local government (e.g., District Collector), Municipal Corporation, or Panchayat, depending on the jurisdiction.

  • The custodian is responsible for preserving the document and making it available when needed (e.g., during a medical emergency).

• Modification (2023): The onus of distribution has shifted (see below), but the custodian remains a key preservation point.

4. Distribution of Copies

• To Nominated Representative:

  • Source: Para 198.2 of Common Cause (2018).

  • A copy must be provided to the person(s) named as the nominated representative (e.g., a guardian or close relative appointed to enforce the directive).

• To Family Physician:

  • Original Guideline (2018): The JMFC was to forward a copy to the family physician.

  • Modified Guideline (2023): This responsibility now lies with the executor, who may hand over a copy to their physician directly.

• Purpose: Ensures key stakeholders (proxy, doctor) have access to the directive.

5. Incorporation into Digital Health Records (Optional)

• Source: Para 198.3.6 of Common Cause (2018).

• Requirement: The executor may choose to incorporate the Advance Directive into their digital health records, if such a system exists (e.g., India’s Ayushman Bharat Digital Mission).

• Status: This is optional and depends on the availability of digital infrastructure.

6. Preservation and Additional Copies

• Original Guidelines (2018):

  • The JMFC was required to:

    • Retain one copy in their office.

    • Forward a copy to the Registry of the District Court for preservation in digital format (Para 198.3.3).

• Modified Guidelines (2023):

  • Deleted Requirement: The JMFC’s role in preservation and forwarding was removed.

  • New Process: The notary or gazetted officer attests the document and records satisfaction, but preservation is now primarily with the custodian (local government official).

  • The executor or custodian may still choose to store a digital copy with the District Court or another authority, though this is no longer mandatory.

7. Shifted Responsibilities

• Original (2018): The JMFC had to inform the nominated representative and family physician.

• Modified (2023):

  • The notary or gazetted officer only needs to inform the nominated representative (not the immediate family unless specified).

  • The executor is now responsible for providing a copy to their family physician, reducing judicial involvement.

Summary of Changes (2018 vs. 2023)

Aspect 2018 Guidelines 2023 Modifications

Attestation JMFC countersignature Notary or gazetted officer attestation

Copy to Family Physician JMFC’s duty Executor’s duty

Preservation JMFC forwards to District Court Registry Custodian (local govt) holds; no mandatory court filing

Notification JMFC informs family and representative Notary informs only nominated representative

Current Procedure (March 5, 2025)

1. The executor signs the Advance Directive in front of two independent witnesses.

2. The witnesses and a notary/gazetted officer attest it, recording that it was voluntary and understood.

3. The original is handed to a local government custodian (e.g., Municipal Corporation official).

4. Copies are given to the nominated representative and family physician by the executor.

5. Optionally, it can be added to digital health records.

Practical Example

• Execution: John, 45, signs his Advance Directive with two friends as witnesses, and a notary attests it.

• Recording: The notary notes, “John executed this voluntarily with full understanding.”

• Preservation: John submits it to the Municipal Corporation, gives a copy to his wife (nominated representative), and emails it to his doctor.