On 02 Aug, 2025, Senior Today hosted their weekly Health Live Webinar with a Palliative Medicine Specialist, Dr Smriti Khanna who spoke on and answered questions about Living Will: Why it Matters and How to Make One.
About Dr Smriti Khanna:
Dr Smriti Khanna is a Consultant in the Section of Palliative Medicine at P.D. Hinduja Hospital, with a focus on Supportive and Home-based Care. She practises both adult and paediatric palliative care, with a strong interest in medical ethics and end-of-life decision-making. She assists patients in drafting their Living Will, ensuring their healthcare choices are understood and respected.
Dr Khanna completed her Internal Medicine residency at St. John’s Hospital, Bangalore, and served as a Senior Resident in Hemato-Oncology at SGPGI, Lucknow. She went on to complete her MSc in Palliative Medicine from Cardiff University, UK. She has six years of experience in Palliative Care.
With six years of teaching experience, she has trained residents, published original research, mentored fellows, and contributed to government-led training programmes in Maharashtra.
Universally and medically, a good death is one where:
- The individual knows that the death is near
- Understands what happens at this time
- Has control over their pain and other symptoms
- Able to maintain one’s own dignity and privacy
- Being able to decide one’s places of death- home, hospital, native place
- To be able to access specialist care, psychosocial support and emotional support
- To have the option to get admitted with hospice services to help manage the symptoms or if managing the symptoms of end of life becomes difficult at home
- To be able to say farewell to ones near and dear ones
- To have the option of making an advance directive and ensuring that ones wishes are actually followed
- Having the choice of not necessarily prolonging ones life
Some call the USA, the laboratory for patient autonomy and patient rights. This is interesting since a lot of the individualism that is a part of medical ethics today has been developed in the west and the US has always been a strong contender.
Once a lot of the equality laws started to come in place, that signalled the end of medical paternalism.
Medical paternalism is a situation/ atmosphere in which “the doctor is always right. The doctor knows best.” And as a patient, seeking care, he has to follow what the doctor says.
This coincided with the era of informed consent and decision making.
This is why now, wherever you go in the world, you, the person undergoing treatment, has to give his informed consent.
Prior to the 1960s, medical progress was not high. A lot of diseases were not even considered for treatment which are now thought and managed as curable- such as cholera, small pox, chicken pox, malaria, tuberculosis. There was not even adequate treatment for the non communicable diseases at the time, such as heart attacks, strokes.
However, from the onset of the 1960s, medical research and development shot up and there was a lot of focus on intensive care which helped us provide and focus on artificial life support. This primarily started in the western society and then moved on to the rest of the world.
This was also the beginning of organ transplants.
The system of having an intensive care unit (ICU) also started at this point of time. With the starting of ICU, also came the medicalisation of death. Prior to this, if an individual was very sick, treatment would happen either at the ward or at home.
The concept of living wills was started by a Human Rights Lawyer in Chicago. The idea behind it was that the patient should get a choice of taking charge of their last days.
In the 1990s, the Patient Self Determination Act came in which stated that it is the patient who gets to decide what happens to them.
One decade later, the conversation around Advance Care Planning started happening and this is also where Advance Medical Directive as a document came into being. It also started getting linked with the US Health Insurance, appointment of a healthcare proxy, making of living will, DNR orders. It originated in the US and has now found a place in at least the major, metropolitan cities in India.
In August 2015, an End of Life Care Task Force was formed with various different medical societies.
Palliative care is the care of individuals with chronic illness and end of life is one aspect of palliative care.
Palliative care professionals have taken a keen interest in the rights of patients around their end of life.
The Common Cause vs the Union India judgement which was passed in 2018 laid down a judgement on how a living will/ advance medical directive needs to be made. Some of the key aspects of this judgement were:
- All adults with the capacity to consent have the right to decide and autonomy.
- A person who has come of age, has the right to refuse a specific treatment or all treatment or want an alternative treatment even if such decision entails the risk of death.
- This can be done by the making of an advanced medical directive which is free from any of these reasonable doubts. Which specifies that he/ she does not wish to be treated, in that case such a directive has to be given effect to.
In 2023, this judgement was simplified by the Supreme Court to make the administrative process easier.
An advance directive talks about an individual’s health aspects after reaching a certain point and health in their life- what treatments do they want/ do not want.
The living will is activated only in times of terminal illness.
A healthcare power of attorney is a part of the living will and also a part of the advanced directive sometimes.
Do Not Resuscitate and Do Not Intubate Orders are orders which are signed in the hospital.
Organ donor directive is also a part of the advanced medical directive which states whether you’d like to donate your organs or not.
How to make a living will:
Step 1: Understanding the answers to questions like- what is a living will? Who should make it? When is it activated?
Step 2: understanding your preferences, documenting them. Also discussing them with your doctor, if needed.
Step 3: Choosing your power of attorney, informing them and documenting the same.
Step 4: Signing and notorising the living will in the presence of 2 witnesses
Step 5: submission of the will to the authorities
Who should make a living will?
- You need to be over the age of 18 to make one. Everyone is over the age of 18 and healthy but is thinking of a situation which is bad such as a road traffic accident which leads to severe brain injury, causing a vegetative state.
- Any individual who has been diagnosed with a chronic and progressive illness. These people need to make a will for a situation wherein the disease has progressed and the individual is unable to make their medical decisions.
- Individuals who have been diagnosed with a devastating illness which allows them only a few months to live.
When is a living will implemented?
- Treating doctors must be convinced that you’re suffering from a. Terminal illness the cannot be cured/ improve your quality of life in any way/ one that can leave you in a persistent vegetative state.
- You are in a position where you are unable to make decision about your health.
A template for the living will has been attached as a pdf to help you, in case you would like to make your living will.
Section 1: Personal particulars
Section 2: Medical Preferences and directives pertaining to life sustaining treatments
Section 3: Wishes and desires during the end of life
Section 4: Nomination of a surrogate decision maker/ medical power of attorney
Section 5: Directions to be followed after death. This is an optional section.
How to choose a medical power of attorney:
- They should preferably be in the same city as you
- They should be of your age/ younger
- Think of the fact if they have an illness that might incapacitate them even before you
- Someone you trust and knows your medical preferences
Make 5 copies of the notarised will, the distribution will be as follows-
- Self
- Power of attorney
- Doctor/ treating physician
- Hospital
- Local govt office
