Enhancing Advance Care Planning in India through a 12-step Pathway

Abstract

Background
Advanced care planning (ACP) and advance medical directives (AMDs) are vital for aligning medical decisions with patient preferences, particularly for end-of-life care. The 2018 Supreme Court judgment in India established the legality of AMDs, enabling patients to exercise their autonomy. Recent amendments in 2023 simplified procedural requirements, replacing judicial magistrate approval with a streamlined two-tier medical board system. This article proposes a culturally sensitive and practical 12-step framework for implementing ACP and AMDs in India.

Materials and methods
A structured and consensus-driven process was undertaken by experts in palliative medicine, neurology, critical care, and geriatrics, supported by key medical organizations. The development process included multiple iterations, public consultations, and feedback from legal and medical stakeholders. The framework integrates legal, ethical, and cultural considerations to address procedural and systemic challenges in ACP implementation.

Results
The proposed 12-step pathway focuses on three phases: creating living wills, periodic reviews and updates, and executing AMDs. Key components include initiating discussions, identification and appointment of surrogate decision-makers, ensuring legal compliance through simplified procedures, and providing guidance for withholding or withdrawing life-sustaining treatments. Implementation strategies emphasize public awareness, provider training, and institutional policies to normalize ACP. Simplified legal requirements introduced in 2023 facilitate broader adoption and reduce procedural barriers.

Conclusion
This framework provides a practical, culturally relevant model for ACP in India, ensuring patient-centered, ethical, and transparent end-of-life care. By integrating simplified legal procedures and addressing misconceptions through education and policy initiatives, the proposed approach empowers individuals, families, and healthcare providers to make informed decisions, fostering dignity and autonomy in medical care.

How to cite this article
Damani A, Ghoshal A, Rao K, Nair S, Gursahani R, Simha S, et al. Enhancing Advance Care Planning in India through a 12-step Pathway. Indian J Crit Care Med 2025;29(4):301–307.

Full text

ORIGINAL ARTICLE
Enhancing Advance Care Planning in India through a 12-step
Pathway
Anuja Damani1, Arun Ghoshal2, Krithika Rao3, Shreya Nair4, Roop Gursahani5, Srinagesh Simha6, Raj Kumar Mani7,
Naveen Salins8
Received on: 17 January 2025; Accepted on: 22 February 2025; Published on: 31 March 2025
Ab s t r A c t
Background: Advanced care planning (ACP) and advance medical directives (AMDs) are vital for aligning medical decisions with patient
preferences, particularly for end-of-life care. The 2018 Supreme Court judgment in India established the legality of AMDs, enabling patients
to exercise their autonomy. Recent amendments in 2023 simplied procedural requirements, replacing judicial magistrate approval with a
streamlined two-tier medical board system. This article proposes a culturally sensitive and practical 12-step framework for implementing ACP
and AMDs in India.
Materials and methods: A structured and consensus-driven process was undertaken by experts in palliative medicine, neurology, critical
care, and geriatrics, supported by key medical organizations. The development process included multiple iterations, public consultations, and
feedback from legal and medical stakeholders. The framework integrates legal, ethical, and cultural considerations to address procedural and
systemic challenges in ACP implementation.
Results: The proposed 12-step pathway focuses on three phases: creating living wills, periodic reviews and updates, and executing AMDs. Key
components include initiating discussions, identication and appointment of surrogate decision-makers, ensuring legal compliance through
simplied procedures, and providing guidance for withholding or withdrawing life-sustaining treatments. Implementation strategies emphasize
public awareness, provider training, and institutional policies to normalize ACP. Simplied legal requirements introduced in 2023 facilitate
broader adoption and reduce procedural barriers.
Conclusion: This framework provides a practical, culturally relevant model for ACP in India, ensuring patient-centered, ethical, and transparent
end-of-life care. By integrating simplied legal procedures and addressing misconceptions through education and policy initiatives, the proposed
approach empowers individuals, families, and healthcare providers to make informed decisions, fostering dignity and autonomy in medical care.
Keywords: Advance care planning, Cultural factors in health care, Decision-making capacity, End-of-life care, Palliative care.
Indian Journal of Critical Care Medicine (2025): 10.5005/jp-journals-10071-24938
Hi g H l i g H t s
Advanced care planning (ACP) and Advance Medical Directives
(AMDs) empower patient-centered end-of-life care. Following India’s
2018 Supreme Court ruling and 2023 procedural simplications,
this article proposes a 12-step culturally sensitive framework to
implement ACP and AMDs, emphasizing ethical, legal, and practical
considerations for broader adoption.
in t r o d u c t i o n
In 1950, India adopted its Constitution, embedding the principles
of liberty, equality, fraternity, and justice, inspired by the ideals of
the French Revolution.1 These values formed th e bedrock of India’s
governance and societal framework. Over time, the concept of
liberty has evolved to encompass personal domains, particularly
healthcare decision-making. A landmark development in this
trajectory occurred on March 9, 2018, when the Supreme Court of
India armed the constitutional right to autonomy over medical
decisions under Ar ticle 21.2 This ruling recognized a dvance medical
directives (AMDs) as essential to uphold the r ight to a dignied life,
empowering patients to express their preferences for end-of-life
care and enabling physicians to act law fully in alignment with these
directives.3, 4 The judgment underscored the need for structured
© The Author(s). 2025 Open Access. This article is distri buted under the terms of the Creative Com mons Attribution 4.0 Intern ational License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrest ricted use, distribution, and non- commercial reproduction in any mediu m, provided you give appropriate credit to
the original author(s) and the source, provi de a link to the Creative Commons license, and indicate if changes we re made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the d ata made available in this article, unless othe rwise stated.
1–4,8Department of Palliative Medicine and Supportive Care, Kasturba
Medical College Manipal, Manipal Academy of Higher Education,
Manipal, Karnataka, India
5Department of Neurology, P. D. Hinduja National Hospital, Mumbai,
Maharashtra, India
6Department of Critical Care and Pulmonology, Karunashraya,
Bengaluru, Karnataka, India
7Department of Critical Care and Pulmonology, Yashoda Super
Speciality Hospital, Ghaziabad, Uttar Pradesh, India
Corresponding Author: Arun Ghoshal, Department of Palliative
Medicine and Supportive Care, Kasturba Medical College Manipal,
Manipal Academy of Higher Education, Manipal, Karnataka, India,
Phone: +91 9434890160, e-mail: arun.ghoshal@manipal.edu
How to cite this article: Damani A, Ghoshal A, Rao K, Nair S, Gursahani
R, Simha S, etal. Enhancing Advance Care Planning in India through a
12-step Pathway. Indian J Crit Care Med 2025;29(4):301–307.
Source of support: Nil
Conict of interest: Dr Raj Kumar Mani is associated as the National
Advisory Board Member of this journal and this manuscript was
subjected to this journal’s standard review procedures, with this
peer review handled independently of the National Advisory Board
member and his research group.

Enhancing Advance Care Planning in India through a 12-step Pathway
Indian Journal of Crical Care Medicine, Volume 29 Issue 4 (April 2025)
302
processes that respect patient autonomy while ensuring ethical
and legal compliance.
Globally, the implementation of AMDs reflects diverse
cultural and societal norms. In Western countries, autonomy
often emphasizes individual rights, aligning with the principle of
“negative freedom,” which advocates liberty free from external
interference.5 In contrast, the Indian concept of autonomy, or
Swadharma, integrates personal choices with broader social
responsibilities.5 T his divergence highlights the unique challenges
of incorporating AMDs into India’s healthcare s ystem. While medical
ethics balances autonomy and benecence for patients capable
of rational decision-making, the trust decit between governance
structures and the public in India poses signicant hurdles to
implementing AMDs.6 Robust oversight mechanisms are crucial
to balance patient autonomy with safeguards against potential
misuse.7 Hence, even in the presence of an AMD, the Supreme Cour t
of India recommends a “shared decision -making” process with the
designated surrogate.3
In India, cultural and structural factors complicate the
adoption of AMDs. Challenges include the absence of universal
health coverage, mistrust in healthcare systems, and a collective
approach to decision- making that often places family at the center
of end-of-life decisions. However, rapid urbanization and shifting
family dynamics necessitate more individualized approaches,
making ACP increasingly relevant.8 While the 2018 Supreme Court
ruling marked a progressive step, procedural complexities—such
as the requirement for judicial magistrate involvement—limited
the practical implementation of AMDs. The 2023 Supreme Court
amendments signica ntly addressed these barriers by introducing
a streamlined two-tier medical board review system, replacing
judicial approval, and improving accessibility.3
India’s history of developing end-of-life care guidelines further
contextualizes the implementation of ACP. The Indian Society
of Critical Care Medicine (ISCCM) published the rst guidance
document integrating palliative care into ICUs in 2005, updated it
in 2012, and collaborated with the Indian Association of Palliative
Care (IAPC) in 2014 to release comprehensive guidelines.9–11 These
2014 guidelines have since ser ved as a cornerstone for subsequent
frameworks, inuencing the Federation of Indian Chambers of
Commerce and Industry and the Blue Maple initiative.12,13 The
ICMR’s guidance, meanwhile, specically addressed DNAR direc tives
independently of broad er guidelines. The 2024 ISCCM-IAPC position
statement represents a signicant update, incorporating recent
legal developments and expanding on the principles established
in earlier documents.14
We have emphasized the novelty of the framework, explicitly
stating that while ACP and AMDs have been explored globally,
this is the rst structured 12-step framework tailored to India’s
legal, ethical, and cultural landscape. We highlight how our model
aligns with the 2023 Supreme Court amendments and addresses
procedural barriers to implementing ACP eectively. Our goal
was to produce an updated document that explains the process
of ACP, AMDs, or living wills and decisions to withdraw/withhold
life-sustaining treatments to ensure that it honors the patient’s care
preferences and values for end-of-life care. The objectives of this
document include outlining a p ractical pathway for ACP and AMDs
in India, providing an impleme ntation strate gy for ACP, and raising
awareness about ACP and AMDs among healthcare providers,
legislators, administrators, policymakers, the legal community,
courts, and the public.
MAt e r i A l s A n d M e t H o d s
The preceding work on this document was created by the End-
of-Life Care Commission, led by the Bioethics Unit of the Indian
Council of Medical Research (ICMR). The core group authoring this
document included palliative medicine, neurology, critical care,
and geriatrics experts. This eort received support from the Indian
Association of Palliative Care, the Indian Academy of Neurology,
and the Indian Society of Critical Care Medicine. Thecore group
of experts was selected based on their experience, geographic
representation across India, pub lication history, and citation records.
These experts took part in a modied Delphi process outlined in
a previous publication, and their responses were kept anonymous
to prevent group bias. The nal document went through multiple
iterations and received controlled feedback. The core group’s nal
draft was made available on the ICMR website for public comment
and suggestions. Additionally, it was shared with ethicists, legal
experts, social scientists, and consumer representatives for their
input. The core group thoroughly discussed all suggestions and
comments and incorporated them into the document through
consensus.15
re s u lt s A n d re c o M M e n d At i o n s
The Indian ACP pathway was developed through a structured and
consensus-driven process, resulting in a comprehensive 12-step
framework to address gaps in understanding and implementing
AMDs in India. The framework emphasizes a practical approach
to documenting and executing end-of-life care preferences while
ensuring ethical compliance and sensitivity to individual values.
The pathway is divided into 3 phases (Box 1).
Steps 1–7 outline the process of creating the living will. Step
8 highlights the importance of periodic review of AMDs to reect
any changes in health status or preferences. Steps 9–12 focus on
executing the living will, includi ng clear protocols for withdrawing
Box 1: The proposed 12-step Indian advance care planning pathway
Creation of the living will
Step 1: Initiation of the advance care planning discussion by the
healthcare providers
Step 2: identication and appointment of surrogate decision-
makers
Step 3: Documentation of the wishes and preferences
Step 4: Documentation of the binding refusals
Step 5: Witnessing the living will
Step 6: Registration of the living will
Step 7: Dissemination of the living will
Review of the living will
Step 8: Periodic review and modication of the living will
Execution of the living will
Step 9: Identication of the situation needing implementation of
living will
Step 10: Determination of the person’s capacity to make
healthcare-related decisions
Step 11: Review of the living will by the medical board
Step 12: Implementation of living will

Enhancing Advance Care Planning in India through a 12-step Pathway
Indian Journal of Crical Care Medicine, Volume 29 Issue 4 (April 2025) 303
or withholding life-sustaining treatments and providing legal and
ethical guidance to ensure adherence to the patient’s documented
wishes.
Step 1: Initiation of the ACP Discussion by the
Healthcare Providers
When a healthy individual voluntarily requests information about
ACP, clinicians should clearly explain the process, focusing on the
individual’s values and preferences. Discussions should address how
they wish to communicate their care decisio ns and include guidance
on involving surrogate decision-makers. These conversations
should be conducted privately and respectfully, ensuring the
individual feels supported and informed.
Clinicians should proactively initiate ACP discussions for
patients whose health conditions are anticipated to worsen
or whose life expectancy may be limited. These conversations
should be tailored to the patient’s medical, social, and cultural
context, emphasizing eective communication to explain care
options clearly. Clinicians should explore the pati ent’s preferences,
involve surrogate decision-makers when appropriate, and ensure
discussions are empathetic and priv ate to align care plans with th e
patient’s goals and values.
Step 2: Identication and Appointment of Surrogate
Decision-makers
A surrogate decision-maker, also known as a healthcare proxy or
healthcare power of attorney, is an individual appointed to make
healthcare decisions for someone who has lost decision-making
capacity. The surrogate ensures that the person’s healthcare
choices reect their values, preferences, and prior instructions,
safeguarding the individual’s autonomy even when they cannot
make decisions themselves.
The appointment of a surrogate must be documented,
specifying their authority, the types of decisions they can make,
and a hierarchy if multiple surrogates are designated. This
documentation must align with the legal framework for surrogate
decision-making. Without a documented surrogate, the next-of-
kin hierarchy will apply as outlined in the 1994 Transplantation of
Human Organs Act.
Surrogates must act in the patient’s best interest, considering
all relevant circumstances without discrimination, respecting the
patient’s beliefs and v alues, and consulting family members about
previously expressed preferences. Collaboration with the clinical
team is essential to ensure ethical decisions are consistent with
the patient’s wishes. Surrogates must avoid decisions based on
subjective judgments of quality of life or any intent to hasten the
patient’s death.
Step 3: Documentation of the Wishes and Preferences
Advance medical direc tive (AMD) is a legally recognized document
that enables individuals to record their preferences regarding
medical treatment, includin g end-of-life care, if they lose decision -
making capacity. Under Indian legal provisions, the directive must
be voluntary, precise, and signed in th e presence of two witnesses,
along with countersignature by a notary public or attested by a
gazetted ocer. It can be updated or revoked anytime, provided
the individual remains competent.
The sample AMD template from Vidhi Centre for Legal Policy
includes sections such as personal details of the individual,
specic instructions for treatment (e.g., refusal of life-sustaining
treatments such as ventilator support or cardiopulmonary
resuscitation), appointment of a healthcare prox y, and declaration
and authentication process with signatures of witnesses and the
notary public or gazetted ocer.16
This structured format ensures clarity, legal validity, and
adherence to the individual’s values and preferences in medical
care. These direc tives are voluntary and can be updated or revoked
at any time.
Step 4: Documentation of the Binding Refusals
Binding refusals refer to specic treatments a person explicitly
chooses to decline under certain conditions, as documented
in their AMDs. In the Indian context, as per the guidelines set
forth by the Supreme Court, these refusals are legally binding on
healthcare providers and surrogate decision-makers, provided
the AMD is valid, genuine, and authentic. However, the binding
refusal is not absolute; it is subject to reconsideration through the
shared decision-mak ing process. A binding refusal may include the
rejection of life -sustaining interventions such as cardiopulmonary
resuscitation, mechanical ventilatio n, or dialysis in cases of terminal
illness or irreversible conditions.17
To ensure enforceability, the AMDs must clearly outline
the treatments refused and the circumstances in which these
refusals apply. The document should be signed by the individual
in the presence of two witnesses and attested by a notary or
gazetted ocer.17 While surrogate decision-makers must honor
these refusals, clinicians may override them if they are deemed
inapplicable or have significant uncertainty regarding their
interpretation.18 This framework protects patient autonomy while
maintaining exibility for unforeseen medical scenarios.
Step 5: Witnessing the Living Will
Two impartial individuals must witness a living will, or AMD, to
ensure its authenticity and validity. These witnesses cannot be
related to the executor by blood, marriage, or adoption and
must not have any vested interest in the directive. Additionally,
healthcare professionals involved in the patient’s treatment, such
as the attending physician or treating team m embers, cannot serve
as witnesses.
Step 6: Registration of the Living Will
Registering a living will, or AMD, ensures its legal validity and clar ity
during implementation . When it comes to voluntary decisions, ther e
is no procedural complexity. For individuals with decision-making
capacity, the AMD must be signe d in the presence of two impartial
witnesses and either notarized by a notary public or attested by
a gazetted ocer. This simplied process, introduced in 2023,
replaces the earlier requirement of judicial magistrate approval,
making it more accessible. Addition ally, individuals are encoura ged
to deposit a copy of the AMD with a designated custodian, such
as a healthcare institution or local government oce, to facilitate
easy verication when needed.
For individuals without decision-making capacity, the process
involves consultation with surrogate decision -makers and hospital
medical boards, as outlin ed in the legal framework. The appo inted
surrogate must ensure that decisions align with the individual’s
documented preferences or, in the absence of an AMD, act in the
patient’s best interest. T he process for withholding or withdrawing
life-sustaining treatments in such cases requires the involvement
of the medical boards to ensure ethical and legally compliant

Enhancing Advance Care Planning in India through a 12-step Pathway
Indian Journal of Crical Care Medicine, Volume 29 Issue 4 (April 2025)
304
decision-making. A notary public or a gazetted ocer must also
attest to the document to further reinforce its legal standing. This
process ensures that the living will is unbiased and represents the
free and informed consent of the individual.
Step 7: Disseminating the Living Will
Once living is executed, it must be shared with relevant healthcare
providers and included in the in dividual’s medical records to ensure
accessibility during critical decision-making. A copy should also
be provided to the appointed surrogate decision-makers and
family members (if desired) and stored securely with a designated
custodian, such as a healthcare institution or local authorit y. While
ensuring proper dissemination, strict measures must be taken
to maintain the privacy and confidentiality of the individual’s
directives.
Step 8: Periodic Review and Modication of the Living
Will
A living will should be reviewed every 1–3 years or sooner if
signicant life events occur, such as changes in health, relatio nships,
or living arrangements (e.g., a move, diagnosis of a serious illness,
or divorce). Regular reviews ensure the document aligns with
the individual’s preferences and circumstances. Any updates or
modications must be do cumented, signed, and attested following
legal requirements. Additionally, these changes should be promptly
shared with all relevant parties, including healthcare providers,
surrogate decision-makers, and document custodians, to avoid
ambiguity during implementation.
Step 9: Identication of the Situations Needing
Implementation of Living Will
Implementing a living will, or AMD occurs when a patient with a
chronic or life-limiting condition experiences signicant disease
progression and meets specic criteria outlined in the Supreme
Court’s 2023 guidelines. This includ es patients who are terminally ill,
have lost the capacity to make or communic ate healthcare decisions
and require a shift in treatment focus toward comfort, symptom
management, quality of life, and dignity rather than aggressive
or life-sustaining interventions that are deemed potentially
inappropriate or have no clinical benet.
Step 10: Determination of the Person’s Capacity to
Make Healthcare-related Decisions
Assessing decision-making capacity is essential to determine
whether a patient can make inform ed medical decisions, including
implementing a living will or AMD. The evaluation focuses on four
abilities: understanding the medical information, appreciating its
relevance to their condition, reasoning through risks and benets,
and expressing a consistent choice.19 A face-to-face assessment
using open-ended questions is conducted, and for patients with
cognitive or psychiatric impairments, additional evaluations
or consultations with specialists may be required. Capacity is
decision-specic and context-dependent, meaning it may vary
across dierent decisions. In In dia, this process aligns with Supreme
Court guidelines, requir ing thorough documentation of ndings. If
capacity is lacking , care decisions must adhere to the AMD or involve
the appointed surrogate decisio n-maker, ensuring alignment wi th
the patient’s documented preferences.
Step 11: Review of the Living Will by the Medical
Boards
The 2023 Supreme Court guidelines outline the following steps
for implementation:
• Verification of AMD validity and applicability: The treating
physician must conrm that the AMD is valid, authentic, and
applicable to the patient ’s medical condition. The directive must
have been properly exe cuted, with attestation by two impar tial
witnesses and a notar y public or gazetted ocer. The physician
must also conrm that the patient cannot expre ss their choices.
• Constitution of the primary medical board (PMB): The hospital
constitutes a PMB to independently review whether withholding
or withdrawing life-sustaining treatment (LST) aligns with the
patient’s documented wishes. The PMB includes the treating
physician and two subject experts with at least 5 years of
experience. The PMB must complete its review and provide a
recommendation within 48 hours.
• Communication with family or surrogates: The treating team
must inform the patient’s next of kin, guardian, or surrogate
decision-makers (as mentione d in the AMD). They should ensure
that these individuals understand the patient’s condition,
the rationale for implementing the AMD, and the PMB’s
recommendation. This step se eks consensus and addresses any
concerns.
• Secondary medical board (SMB) Review: A secondary medical
board is recommended for all cases of treatment limitation for
the patient who has lost capacity or if there is disagreement
among family members, surrogate decision-makers, or the
treating team. The SMB includes one registered medical
practitioner, the chief medical ocer sta, and two independent
subject experts with at least ve years of experience who are
not part of the PMB. The SMB mus t review the case and provide
its opinion within 48 hours. If disagreements arise during this
process, such as between the PMB and the SMB, the case can
be escalated to the High Court for resolution.
• Final d ecision and notication: If the SMB concurs with the PMB’s
recommendation, the hospit al records the decision and noties
the Judicial Magistrate First Class (JMFC) as required by law
(Fig. 1).
Step 12: Implementation of the Living Will
Implementing the living will, or AMD, involves respecting and
adhering to the patient’s documented preferences. Healthcare
interventions explicitly refused in the living will not be provided,
while symptom control, supportive care, and comfort should be
prioritized. The treatin g team implements the AMD by withholding
or withdrawing LST following the patient’s wishes.
The healthcare team must ensure comprehensive palliative
care throughout implementation to alleviate suffering and
uphold the patient ’s dignity. This includes addre ssing the patient’s
physical, psychological, social, emotional, and spiritual needs.
Family members, caregivers, and surrogate decision-makers
should also receive support during this transition, including
bereavement support af ter the patient’s death. Open and eec tive
communication between surrogate decision-makers, family
members, and the healthcare team is essential to reduce fear,
confusion, and guilt, facilitate decision-making, and minimize
conicts over the patient’s care.

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Indian Journal of Crical Care Medicine, Volume 29 Issue 4 (April 2025) 305
Cultural and religious considerations must also be respected
while implementing the living will. This framework, aligned with
the Supreme Court’s 2023 guidelines, ensures that AMDs are
applied transparently, ethically, and compassionately, prioritizing
the patient’s autonomy and dignity while fostering a supportive
environment.
Implementation, Dissemination, and Review Strategy
for the ACP Pathway
Implementation Strategy
• Patients and families: Develop educational tools (pamphlets,
videos, guidebooks) addressing key topics like palliative care,
stopping treatment, and healthcare surrogates.
• Healthcare providers and institutions: Train providers on ACP,
documentation, and execution. Hospitals and insurers will
integrate processes for living will implementation.
• Organizations and government: Establish institution-wide
policies, designate implementation leaders, create alert systems,
and provide a supportive legal framework.
Dissemination Strategy
Make the living will document accessible as an e-book on the
ICMR website, publish it in a peer-reviewed journal, and distribute
printed copies to key stakeholders, including medical institutes,
government bodies, legal rms, and courts.
Review Strategy
Update the living will document every 3 years to reect changes
in technology, law, and public perception. Conduct audits and
qualitative studies to monitor implementation, impact, and user
experiences.
This approach ensures effective implementation, broad
dissemination, and continuous improvement of ACP practices in
India.
discussion
Advanced care planning is essential for ensuring patient care aligns
with individual preferences, particularly during declining health.
Practical ACP discussions should be patient-driven, focusing on
anticipated health changes and guided by the patient’s values.
Clear documentation of preferences and the appointment
of surrogate decision-makers are vital to upholding patient
autonomy. The origins of living wills and AMDs trace back to the
1970s, emerging from debates within the Euthanasia Society of
America. Human rights a dvocate Luis Kutner conceptualized living
wills as tools to align treatment decisions with patient consent.20
California enacted the rst living will legislation in 1976, setting
a precedent for integrating end-of-life preferences into legal
frameworks. Overtime, ACP evolved globally, emphasizing ongoing
communication with families and physicians over a sole focus on
legal directives.21 The United States, for instance, now integrates
AMDs with tools like healthcare power of attorney and physicians’
orders for life-sustaining treatment (POLST).21 At the same time,
European countries exhibit variability in approaches, with some
favoring physician-assisted dying over formalized AMDs.22
Enhancing ACP in India through a 12-step pathway represents
a transformative approach to improving patient-centered care,
Fig. 1: Summary of the Supreme Court of India’s legal guidelines for decisions to forgo life-sustaining treatment. Adapted from Mani RK, Simha
S, Gursahani R. Simplied Legal Procedure for End-of-life Decisions in India: A New Dawn in the Care of the Dying? Indian J Crit Care Med. 2023
May;27(5):374–376. DOI: 10.5005/jp-journals-I0071-24464. PMID: 37214121; PMCID: PMC10196646

Enhancing Advance Care Planning in India through a 12-step Pathway
Indian Journal of Crical Care Medicine, Volume 29 Issue 4 (April 2025)
306
particularly in a culturally diverse and resource-constrained
setting. Like other low- and middle-income countries (LMICs),
India faces signicant barriers to ACP implementation, including
cultural reluctance to discuss end-of-life care, family-centric
decision-making, and limited awareness among patients and
providers.23 These challenges are compounded by healthcare
disparities and a lack of infras tructure in rural areas, where most of
the population resides. Despite these challenges, India has taken
progressive steps, such as the Supreme Court’s recognition of
advance directives in 2018, though operationalizing these legal
provisions remains limited. A structured pathway could build
on this foundation by addressing awareness gaps, fostering
community engagement, and tailoring ACP practices to align
with cultural norms. Compared to LMICs in Africa and Asia, where
community-based palliative care models have facilitated ACP,
India can adopt similar appro aches, leveraging trusted community
health workers and local leaders to normalize discussions and
overcome cultural barriers.24,25 At the same time, lessons from
High-Income Countries (HICs) such as the U.S., Canada, and
Australia highlight the impor tance of integrating ACP into routine
healthcare through legal instruments, structured training, and
public awareness campaigns.26 Unlike HICs with well-established
frameworks, LMICs often rely on pilot programs, as seen in Iran
and Lebanon, where limited resources have necessitated creative,
community-driven solutions.27,28 In India, a 12-step pathway
could address these disparities by embedding ACP into clinical
practice and public health initiatives , focusing on capacity building
for healthcare providers and scalable delivery models such as
telemedicine. Training healthcare providers, a cornerstone in
HICs, could be adapted to Indian conte xts by developing culturally
sensitive communication strategies and empowering providers
to initiate ACP discussions eectively. Furthermore, it is crucial to
generate evidence to monitor and rene interventions; India could
emulate evidence-bas ed approaches like the U.S. POLST program
while tailoring them to resource constraints and population
needs.29 Community engagement, a proven strategy in both
LMICs and HICs, will be critical in India to build trust and promote
awareness, particularly in rural areas with low health literacy. By
prioritizing localized solutions, such as involving religi ous leaders
and integrating ACP into existing health sys tems, India can ensure
that the pathway is eective and culturally a cceptable. Th e 12-step
framework must also strengthen legal and policy frameworks
to provide clarity for patients and healthcare providers alike,
ensuring that ACP discussions lead to actionable outcomes.
Ultimately, the success of this initiative will depend on its ability
to bridge the gap between urban and rural healthcare settings,
address systemic inequities, and create a model that can serve
as a benchmark for other LMICs. By combining lessons from HICs
with innovations from LMICs, India’s pathway can normalize ACP,
improve the quality of end- of-life care, and set a global precedent
for implementing patient-centered care in complex healthcare
environments.
This work has several limitations, including the involvement
of a small expert group, which highlights the need for broader
stakeholder engagement to validate the ndings. Additionally,
there is a lack of real-world im plementation data, making it essential
to conduct pilot studi es to evaluate the feasibility of the framework .
There are also challenges in operationalizing the framework, such
as institutional resistance and the varying healthcare inf rastructure
between urban and rural areas.
Future Directions
To enhance ACP, eorts should prioritize imp roving legal literacy and
addressing misconceptions through public education campaigns
that present ACP as a proactive and empowering process. It is
crucial to increase access to legal and me dical resources, especially
in underserve d areas, and to train healthcare providers in culturally
sensitive communication and documentation. Future frameworks
should focus on integrating ACP into routine healthcare practices,
addressing fears, and providing adaptable solutions suited to
diverse cultural and resource settings. Conducting regular policy
reviews will ensure that ACP remains relevant, accessible, and
aligned with evolving medical and societal needs. Additionally,
implementation audits are necessary to track the real-world
eectiveness of the framework. There should also be qualitative
and quantitative research on the adoption of AMDs across dierent
demographics. Policy advocacy strategies are essential to ensure
the seamless integration of ACP into India’s healthcare and legal
frameworks. Community-based interventions, including public
awareness campaigns and the incorporation of ACP into medical
curricula, are vital for promoting understanding and acceptance.
conclusion
Advance care planning and AMDs are essential components of
healthcare that involve comprehensive guidance and up-to-
date information for healthcare providers, individuals, families,
caregivers, and the public. The proposed twelve-step pathway
provides an algorithmic approach to ACP and AMDs in India. This
framework oers a structured method for implementing ACP and
AMDs, ensuring that end- of-life care is ethical, patient-centered, and
legally sound. While th e streamlined legal procedures introduced in
2023 enhance accessibility, further research is needed to promote
wider adoption of these pr actices and to evaluate the eectiveness
of AMD implementation across diverse healthcare settings.
Ethics Approval
CTRI registration or Ethics approval and the need for consent
to participate in this study were deemed unnecessary as no
patient participated. This is according to guidelines by the
Indian Council of Medical Research. Handbook on National
Ethical Guidelines for Biomedical and Health Research Involving
Human Participants. (Mathur R, ed.). Indian Council of Medical
Research; 2018. Available on https://www.icmr.gov.in/icmrobject/
uploads/Guidelines/1724914217_handbook_on_icmr_ethical_
guidelines_2018.pdf.
Au t H o r s ’ c ontributions
Anuja Damani: Writing—review and editing, projec t administration;
Arun Ghoshal: Writing—review and edi ting, project administration;
Krithika Rao: Writing—review and editing; Shreya Nair: review
and editing; Roop Gursahani: Conceptualization, methodology,
resources; Srinagesh Simha: Conceptualization, methodology,
resources; RK Mani: Conceptualization, methodology, resources;
Naveen Salins: Conceptualization, methodology, resources,
writing—original draft, supervision.

Enhancing Advance Care Planning in India through a 12-step Pathway
Indian Journal of Crical Care Medicine, Volume 29 Issue 4 (April 2025) 307
or c i d
Anuja Damani https://orcid.org/0000-0002-4469-0846
Arun Ghoshal https://orcid.org/0000-0001-9975-2568
Krithika Rao https://orcid.org/0000-0002-7679-4850
Shreya Nair https://orcid.org/0009-0008-0844-3558
Roop Gursahani https://orcid.org/0000-0002-6092-1595
Srinagesh Simha https://orcid.org/0000-0003-1560-0079
Raj Kumar Mani https://orcid.org/0000-0003-4759-8233
NaveenSalins https://orcid.org/0000-0001-5237-9874
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