Tamil Nadu issues guidelines for Advance Medical Directives to uphold patient autonomy
In a significant step to strengthen patients' autonomy in end-of-life medical care, the Tamil Nadu government has issued guidelines for Advance Medical Directives (AMD), allowing adults to formally record their wishes on withholding or withdrawing medical treatment when they become incapable of communicating or making healthcare decisions.
The “Tamil Nadu Advance Medical Directive Guidelines, 2026” have been issued to implement AMDs across the State. The guidelines follow the Supreme Court's judgment in the Common Cause case, which laid down principles and procedures for the execution of AMDs, and gave effect to passive euthanasia in circumstances where AMDs exist and where they do not.
Shireen Yachu, Senior Resident Fellow at the Vidhi Centre for Legal Policy, explained that in the recent case of Harish Rana vs Union of India, the Supreme Court had asked States to file responses on the status of implementation of the Common Cause orders. Those orders included setting up of medical boards and appointing custodians for the storage and safe keeping of AMDs. States responded with orders of the mechanisms they had put in place.
Ms. Yachu described the Tamil Nadu guidelines as a significant step. “It allows individuals to retain autonomy over their own healthcare decisions. It enables them to make healthcare decisions for a time when they may no longer have the capacity to make those decisions themselves,” she said.
As per the guidelines, every adult has the right to execute an AMD in the prescribed form. An AMD takes effect only when the executor becomes incapable of making or communicating informed decisions regarding medical treatment. It must name a guardian or close relative authorised to consent to refuse or withdraw medical treatment in the event the person loses decision-making capacity.
A copy of the AMD must be given to the guardian or close relative, the family physician, and the Joint Director of Health Services (JDHS) or any other officer notified by the government, who will act as custodian. The executor may withdraw or alter the AMD at any time while he or she retains capacity.
If the executor becomes terminally ill and is undergoing prolonged medical treatment with no hope of recovery, and does not have decision-making capacity, the treating physician, upon being made aware of the AMD, must ascertain its genuineness. The guidelines also state that every treating institution must maintain a panel of experts to form a Primary Medical Board when required. This board should consist of the treating physician and two experts from the institution with at least five years of experience.
In addition, the JDHS must maintain a panel of registered medical practitioners from which the treating institution can choose to constitute a Secondary Medical Board. These two boards must determine whether the AMD's instructions to withdraw or refuse further treatment should be followed.
The hospital where the patient is admitted must convey the decision of the two boards, along with the consent of those named in the AMD, to the jurisdictional Judicial Magistrate First Class. If the Secondary Medical Board refuses permission to withdraw medical treatment, the persons named in the AMD, or the treating physician, or the treating institution can approach the High Court. The guidelines also outline procedures to be followed when there is no AMD.
Ms. Yachu noted that the executor may incorporate the AMD into digital health records. “While this provides an important foundation, it is equally critical for the State to establish the necessary infrastructure to ensure interoperability and ease of access,” she said. If a person uploads an AMD to a hospital's records in one district, mechanisms should enable access if they subsequently seek care in another district or State.
She also highlighted that another priority for Tamil Nadu should be training of doctors to ensure better understanding of withholding and withdrawal of medical treatment and its implementation. “There are still moral and ethical contentions among healthcare professionals on sustaining treatment, Do Not Resuscitate orders and AMDs,” she said.
The guidelines mark an important step in ensuring that individuals can make informed choices about their own medical treatment, even when they are no longer able to express those choices themselves. Effective implementation, including adequate infrastructure and training for healthcare providers, will be crucial to realising the intended benefits.
