End-of-life care (EOLC) represents a critical and often overlooked aspect of healthcare that focuses on providing comfort and dignity to individuals nearing the end of their lives. A peaceful and dignified death is the right of every person with a life-limiting illness. A ‘good death’ can be an outcome of a holistic approach towards the patients, taking into account their wishes, cultural background, ethical considerations alongside symptom management. Despite the high death rate due to chronic terminal illnesses, India seemingly lacks the capacity to provide end-of-life care (EOLC). As per the Economist Intelligence Unit report in 2015 India ranks 67th out of 80 countries which were studied for quality of death. The major factors that act as a barrier for practicing EOLC in developing countries include failure to recognize EOLC as a requirement of public health, lack of related systematic data, and lack of a national-level policy. To top it off legal ambiguity further deters physicians from initiating EOLC discussions, resulting in the initiation and continuation of invasive life-sustaining procedures at end-of-life. However, the duty of care for the physician is bound not only by the national laws but also the principles of professional ethics (autonomy, non-maleficence, beneficence, and justice). The physician bears the duty to save a patient’s life, but this duty does not mean continuing a potentially non-beneficial or harmful treatment which can further increase the suffering of the patient and their caregivers. This type of care goes beyond the traditional curative model, prioritizing symptom relief, pain management, and psychosocial support for both patients and their families. Despite the advancements in healthcare systems worldwide, the provision of quality EOLC remains still inadequate in our country India. Moreover, the issue of inadequate EOLC is particularly significant in our country because of growing burden of chronic diseases and terminal illnesses, such as cancer, neurological disorders, and heart disease. However, the challenges such as resource limitations, cultural barriers, and insufficient training for healthcare professionals are making these decisions further difficult. Hence the need for well-structured and compassionate end-of-life care has become even more urgent. Although there have been efforts to address these issues through national guidelines and institutional policies, there remains a significant gap between what is recommended and what is practiced. The All-India Institute of Medical Sciences (AIIMS), one of the leading healthcare institutions in India, has developed a comprehensive policy on End-of-Life Care. We have used this policy as a gold standard for making our EOLC decisions. (Annexure – 1) This policy addresses the issue in four parts: (i) recognition of potentially non-beneficial or harmful treatment by physicians, (ii) consensus among all caregivers on potentially non-beneficial or harmful treatment and initiation of the best supportive care pathway, (iii) initiation of EOLC pathways, and (iv) symptom management and ongoing supportive care until death. This policy outlines best practices in symptom management, referral to palliative care services, communication with patients and families, and the importance of cultural sensitivity and psychological support. However, the implementation and adherence to these guidelines require regular evaluation to ensure they are being effectively followed in clinical practice. This clinical audit aims to have a standardized protocol in our unit and to assess the extent to which EOLC practices at AIIMS align with the institution’s established policy on EOLC at our centre. The audit specifically assessed key components such as futility criteria, consensus among treating physicians and the critical care team, agreement with family members regarding futility and documentation, types of EOLC decision and pre EOLC assessment process thereof. It also evaluated various end-of-life care (EOLC) decision-making processes, included no CPR, no intubation, no vasopressors, and no dialysis, no blood transfusion, no routine Labs, no higher antibiotics as well as compliance with documentation, of these parameters. Additionally, it reviewed checklist compliance for communication and initiation of end-of-life care. This audit aimed to identify areas where our policy was successfully implemented and those requiring improvement, contributing to the enhancement of EOLC quality at our centre. By systematically assessing the alignment between clinical practices and institutional policy, this audit intended to provide actionable recommendations for improving EOLC policies at our centre. Additionally, it may offer valuable insights for better application of EOLC in other healthcare settings across India.
