A good Advance Medical Directive (AMD) is not just a signed form — it is the result of a careful, honest conversation that weighs a person's medical reality, their family, their finances and, above all, their own wishes. These guidelines from the Jeevan Mukti Trust outline what we consider when helping someone draft a directive that is clear, realistic and truly their own.
These notes summarise the full guidelines deck prepared by Dr. Rajanikanth for the Jeevan Mukti Trust. The complete slides are available to download at the end of this article.
1. Assess decision-making capacity
There is currently no single fixed legal test for this in India, so we assess capacity across four practical dimensions:
- Understanding — can the person understand and repeat what has been explained to them?
- Reasoning — is there a clear thought process, and can they choose between options?
- Expression — can they explain why they made a particular choice?
- Appreciation — do they appreciate the consequences of accepting or refusing a given intervention?
2. Prognostication
Realistic planning depends on an honest picture of what may lie ahead. Factors to consider include:
- Age and sex.
- Present and past medical and surgical history.
- Current medication.
- Any previous ICU admissions, with details.
- Family history of malignancy and other conditions.
- For accidental head injuries — what to realistically expect.
3. Anticipating future scenarios
It helps to picture the specific situations in which a person may be unable to communicate, so their wishes can be matched to each. For example:
- Completely comatose, with a Glasgow Coma Scale (GCS) score below 6–7.
- Awake but unable to speak or write.
- Awake and able to speak but totally disoriented.
- Awake but unable to communicate due to severe pain or breathlessness.
Throughout, the discussion is anchored in dignity in death and quality of life, which help a person choose the option that is right for them.
4. Finances — where to draw the line
Long-term care has real financial consequences, and an honest conversation here protects families later. We discuss:
- Medical insurance — and, if present, the sum insured.
- The family's financial status and affordability.
- Possible support from family or friends.
- Existing commitments such as bank loans and EMIs.
- Future commitments — children's education and marriage, a spouse's living expenses.
5. Family factors
Without an AMD, the family — starting with the spouse — must decide the line of treatment with no clues from the patient. That can lead to:
- Differences of opinion within the family.
- Difficulty when immediate family (for example, NRI children) are not available.
- Added complications when there is also no property will.
- Disagreement between the family and the treating physician.
- Ill-informed decisions causing unnecessary suffering despite expensive interventions.
- Pressure from relatives and society — and lasting guilt and trauma.
6. Choosing a surrogate
A surrogate is the person nominated by the patient to implement a valid AMD, or to take decisions on their behalf. The patient may nominate a spouse, an adult child or a close friend — whoever is best suited.
The law recommends nominating at least two surrogates, so that if the first is unavailable or declines, a second can step in. A nominated surrogate can override the decisions of other family members.
7. DNR, DNI and DNH
These instructions — Do Not Resuscitate, Do Not Intubate and Do Not Hospitalise — can only be implemented once the AMD has been verified.
- In acute trauma, paramedics are still expected to perform CPR as a basic life-saving measure.
- Once the AMD is verified, and if the patient then suffers a cardiac or respiratory arrest, these instructions must be followed.
- If the patient collapses at home, the responsibility for DNR/DNH falls on the family — which is exactly why the patient should discuss these decisions with them in advance, so their wishes are understood and respected.
8. A note on DAMA
Discharge Against Medical Advice (DAMA) can arise from a difference of opinion between family and physician, or from financial burden. Where free treatment is available — at a government hospital or an NGO — moving there is technically not DAMA. Be aware that if the patient holds a life insurance policy, a DAMA can complicate claims; the death certificate should record death due to natural causes for trouble-free settlement.
Draft yours with expert guidance
We walk you through every one of these considerations — gently, and at your pace.