BODY DONATION IN INDIA

 INTRODUCTION

Recently, I heard of an incident where the body of a person who had got registered for body donation was not accepted by the concerned hospital, and the family had to make last minute arrangements  for cremating the body. This prompted me to research this topic in detail and to share the information I gathered, in the form of  a detailed post for furthering our understanding of the whole concept of body donation in India.

Body donation refers to the donation of the whole body after death for the purpose of medical research and education. It enables medical students and researchers to better understand the intricacies of the human body for the advancement of science.

WHO CAN DONATE THEIR BODY-

Almost anyone can become a whole body donor after death, irrespective of age, gender, caste, or religion. There is no upper age limit. Even those who are very ill could be eligible, since researchers may often require to study the bodies of donors who suffer from some specific disease or medical condition.

PRELIMINARY STEPS -

1) Identify the nearest hospital/medical college/NGO that will accept whole body donations. Only those hospitals that have been authorised by the State Govt. to  accept such donations can do so.

2) Contact the chosen hospital to understand their requirements, since each hospital may have their own set of rules and procedures.

3) Get registered under the voluntary body donation program. The registration forms are generally available online. Though registration is not mandatory, it will considerably smoothen the whole process.  

It is mandatory that the registration form (also called Willingness form) be signed in the presence of two legal witnesses.  Most hospitals may insist that atleast one of the witnesses be a next of kin/relative.

It is very important to discuss your intentions to be a body donor with your family, because they are the ones who will be responsible for executing your wishes.

4) Once the duly-filled up forms are submitted, the hospital will provide the following documents -

a) Acknowledgement letter

b) Certificate of honour for the service being rendered to the community

c) The donor I-card having the registration number

d) Contact numbers that the next of kin can use to inform the hospital on the demise of the donor.

DOCUMENTS REQUIRED AT THE TIME OF BODY DONATION-

a) Most important document - Death certificate issued by a doctor (not to be confused with the death certificate issued by municipal authorities.)

b) The donor card

c) If not registered, the family will have to accompany the body and complete the required paper work.

d) Identification document of the deceased (Aadhaar card, Voter's ID or PAN card).

e) Identification document of the family member accompanying the body.

HANDING OVER THE BODY -

VERY IMPORTANT -

The hospital accepting the body donation will not issue a death certificate. 

PLEASE NOTE: If the body is taken to the hospital before obtaining a death certificate, then the body will be declared as "Dead on Arrival"and the hospital will be obliged to notify the police, who will insist on an autopsy, making the body unsuitable for body donation.

If the donor's death has happened in a hospital, then the attending physicians will issue a Doctor's death certificate. If the death occurs at home, then any medical doctor can issue the death certificate. It is necessary for the family to act fast and find a doctor quickly, as the body has to be transported to the hospital within six hours of the time of death.

 In some cases, the hospital will send a vehicle to transport the body. This facility will be extended even if death occurs in a  nearby place within a radius of 100 kms. If the body needs to be kept for upto 48 hrs. before donating, the mortuary facility available in hospitals can be used. 

In case death occurs in another city, the family can contact the hospital where the donor has registered, and they will be able to guide the family to the nearest hospital that is qualified to accept whole body donations, since most hospitals have a tie-up with other hospitals.

CERTAIN INSTANCES WHEN THE DONATION OF A BODY WILL BE REFUSED-

a) If the cause of death is not natural (eg:- murder, suicide etc.)and an autopsy is required.

b) If the hospital cannot retrieve the donor's body within three days of death

c) A whole organ donation has been done, the only exception being eye donation.

d) The deceased is severely overweight or emaciated

e) The deceased was suffering from an infectious disease

f) If the death involved severe trauma to multiple bones 

g) A hospital may also decline a body due to lack of storage space and need at that particular time.

AFTER HANDOVER OF THE BODY-

Once the body is handed over to the hospital, it will issue a "Body Receipt"document. This, along with the doctor's death certificate, will have to be handed over to the Municipal Corporation to obtain the final Municipal death certificate which is required by the legal heir for inheritance.

The hospital will usually hand over some of the hair of the deceased to the next of kin, to be used to perform the last rites.

In India, most hospitals use the bodies for long periods of time. After the initial use for teaching, sometimes the body may be buried so that the hospital can obtain a skeleton. In other cases, the body is cremated, but the ashes are not returned to the family.

NGOs and MEDICAL INSTITUTIONS THAT ACCEPT BODY DONATION -

I) TRIVANDRUM

Dr. Somervell Memorial C.S.I. Medical College and Hospital

Govt. Medical College and Hospital

Sree Gokulam Medical College Trust and Research Foundation

II - CHENNAI

ACS Medical College and Hospital

ESIC Medical College and PGIMSR

Govt. Stanley Medical College

Govt. Medical College - Omandurar

Kilpauk Medical College

Madras Medical College

Sri Muthukumaran Medical College

Sri Ramachandra Medical College and Hospital

Tagore Medical College and Hospital

III- BANGALORE

MVJ Medical College and Research Hospital

Bangalore Medical College and Research Institute

Dr. B.R.Ambedkar Medical College

ESIC Medical College

Kempegowda Institute of Medical Sciences

Rajarajeshwari Medical College and Hospital

Ramaiah Medical College

Sapthagiri Institute of Medical Sciences and Research Centre

St. John's Medical College Hospital

The Oxford Medical College Hospital and Research Centre

Vydehi Institute of Medical Sciences and Research Centre

Zonal Co-ordination Committee of Karnataka for Transplantation (ZCCK)

IV - HYDERABAD

Deccan College of Medical Sciences

Malla Reddy Institute of Medical Sciences

Mediciti Institute of Medical Sciences

Osmania Medical College

Shadan Institute of Medical Sciences and Teaching Hospital and Research Centre

V -MUMBAI

Dadichi Mission - Borivali

Grant Govt. Medical College and Sir JJ Group of Hospitals

HBT Medical College and Dr. RN Cooper Municipal General Hospital

KJ Somaiya Medical College and Research Centre

Lokmanya Tilak Municipal Medical College

Manav Jyot Charitable Trust

Seth GS Medical College

Topiwala National Medical College and BYL Nair Charitable Hospital

VI- KOLKATA

Calcutta National Medical College

College of Medicine and Sagore Dutta Hospital

ESIC Medical College and Hospital

KPC Medical College

Nilratan Sircar Medical College

RG Kar Medical College and Hospital

VII- DELHI_- NCR

Vardhman Mahavir Medical College

Safdarjung Hospital

Army College of Medical Sciences

AIIMS Dept. of Anatomy

University College of Medical Sciences (UCMS)

Maulana Azad Medical College (MAMC)

Lady Hardinge Medical College

Dr. Baba Saheb Ambedkar Medical College

Dadhichi Deh Dan Samiti

 

ORGAN DONATION IN INDIA

Introduction

Organ transplant is a medical procedure by which a person's dysfunctional organ or tissue is replaced by that of a healthy person, thereby restoring its function. Obviously, a transplant can only take place if there is an organ available from a donor. However, owing to the  major scarcity of organs available for transplant in India,  there exists a severe demand and supply mismatch. For eg:- it is estimated that  around 1.8 lakh people suffer from renal failure every year, but the number of renal transplants done is only around 6,000 per annum.

Types of Organ Donation

There are two types of organ donation -

a) Living organ donation - A living person donates an organ (or part of an organ) for transplantation to another person. Living donors are classified as either a near relative (spouse, son / daughter, sibling, parents, grandparents, grandchildren) or a distant relative /friends who will need the permission of the State Authorisation Committee to donate an organ. Living persons can donate a kidney, a lung, and a portion of the liver, pancreas or intestine and still continue to live a normal life.

b) Deceased organ donation - Organ donation from a person who has been declared brain stem dead by a team of authorised doctors at a hospital. A person is said to be brain stem dead when there is an irreversible loss of consciousness , absence of brain stem reflexes and irreversible loss of the capacity to breathe. 

The other type of deceased donor could be a donor after cardiac death. But after natural cardiac death, only a few organs / tissues can be donated such as cornea, bone, skin and blood vessels, whereas after brain stem death, almost 37 different organs and tissues can be donated. 

Organs commonly transplanted from a brain stem dead donor  include kidneys, liver, pancreas, intestines, lungs and heart, with the demand for kidneys being the highest.Tissues that can be transplanted include cornea, skin, bone, veins, muscles, tendons, cartilage, heart valves, ligaments etc. A single donor can save upto eight lives through organ donation and heal upto 50 recipients through tissue donation.

In India, there is an urgent need to promote deceased organ donation, because donation from living persons cannot take care of the increasing demand for organ transplants.

Legislation in India

The Indian Govt. enacted the Transplantation of Human Organs Act in 1994, which  provides a comprehensive system to regulate the removal, storage and transplantation of human organs for therapeutic purposes and for prevention of commercial dealings in human organs. It legalised the concept of "Brain Death", which is now recognised as a legal form of death.

 Brain death is the irreversible and permanent cessation of all brain functions. In situations of brain death, a person cannot sustain his own life, but vital body functions may be maintained in an ICU for a short period of time. Such persons are kept on artificial support to maintain oxygenation of organs so that the organs are in a healthy condition until they are removed. A panel of four doctors has to declare a patient brain dead before the organs can be harvested. This is done after a series of exhaustive tests which are repeated twice in a time frame of 6 hours.

Govt. Agencies

The National Organ and Tissue Transplant Organisation (NOTTO) was set up following the passing of the Transplantation of Human Organs and Tissues (Amendment ) Act of 2011. It functions under the Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India, serving as the apex centre for registering of organs and tissue donation and transplantation in the country. It is also responsible for the overall co-ordination of the procurement and distribution of organs and tissues. 

There are five Regional Organ and Tissue Transplant Organisations  (ROTTO), which function as separate regional branches to oversee the functioning of the state level organisations enlisted under each of them. 

Procedure for organ donation 

To be an organ donor, it is necessary to register and  sign up for organ donation by filling up the prescribed consent form which can be downloaded  from the website of the National Organ and Tissue Transplant Organisation (NOTTO), or accessed from the medical facility that is approached for organ removal. Anyone can register to be an organ and tissue donor once they are 18 years old.

Given below are some of the NGOs with which  you can register in order to pledge your organ(s).

1. MOHAN (Multi-Organ Harvesting and Networking) FOUNDATION - www.mohanfoundation.org;  Ph: 1800 103 7100

2. SHATAYU - www.shatayu.org.in;  Ph: 079 6618 9000

3. GIFT YOUR ORGAN  FOUNDATION - www.giftyourorgan.org;  Ph: +91 9845088989

4. ORGAN INDIA - www.organindia.org;  Ph: 1800 120 3648

Pledging to be an organ donor -

A prospective donor is required to fill out the pledge form available online, after which a Donor Card will be sent, along with a unique Govt. registration number. All pledges are registered with NOTTO. Registering as an organ donor is merely an expression of a person's  intent to be an organ donor and does not carry any legal sanction. 

Deceased Organ Donation

By law in India, organ and tissue donation from a deceased donor cannot take place without the written consent of the donor's family. Therefore, if you have registered as an organ donor, it is very important to talk to your family about your decision to be an organ donor to help them understand your reasons for the same.

 Generally, there is no age bar to organ donation and one or the other organs or tissues can be donated at any age. However, all potential donors will require a virology screen to prevent possible transmission of any disease from the donor to the recipient. Decisions about an organ's usability are made at the time of the donor's death. The suitability of each organ and tissue is decided by the concerned medical personnel.

In India, many cultural and religious beliefs influence the decision making regarding deceased organ donation. Lack of awareness, religious beliefs and superstitions, and lack of faith in the healthcare system are believed to be the most important reasons for the family members refusing to give their consent for the organ donation of their close relatives. These are issues that need to be addressed in order to improve the availability of organs for transplant.

ORGANISATIONS PROVIDING ELDERLY CARE SERVICES IN INDIA

Introduction

The current pandemic has been a life-changing experience for all of us. It has highlighted the extremely fragile nature of our existence, with the ever unfolding tales of human tragedy that we see all around us. It has also thrown into sharp focus the highly vulnerable situation of the elderly in our cities, many of whom are living by themselves, while their children are settled down either abroad or in other cities. Under normal circumstances, they could rest assured that in the event of any crisis, they could count on their children to come and help out. However, in the current situation, this is a luxury that has been ruled out for many, given the various restrictions on international and domestic travel, leaving many of them to have to fend for themselves in an emergency. 

In this scenario, it would be useful to be aware of the various support services in the form of home healthcare services that are being provided by various organisations in the country. Such services have become particularly relevant in the current scenario, where people are wary of going to hospitals which have become a high-risk zone. Recent years have witnessed the emergence of various startups in this burgeoning sector, that make use of modern technology to virtually monitor the health and well-being of their elderly clientele and to provide real-time updates to their children residing elsewhere. 

There are several organisations in the major Indian cities which provide elderly care. Such organisations  can be classified as follows -

(a)  those that have a presence across various cities and provide elderly care along with various other kinds of medical care

(b) those that specialise in elderly care and have a presence across various cities

(c) those that provide specialised elderly care services that are localised in  any given city.

In this post, I have sought to give a listing of some of the organisations  providing elderly care across various cities in India.

A- Organisations with a pan-Indian presence  providing various kinds of home healthcare services, including Elderly Care. 

1. PORTEA

Services available  in BANGALORE,  DELHI -NCR,  MUMBAI,  CHENNAI,  KOLKATA,  HYDERABAD,  PUNE,  LUCKNOW, CHANDIGARH,  JAIPUR,  INDORE,  VISHAKAPATNAM,  KOCHI, KOZHIKODE,  TRIVANDRUM,  THRISSUR,  BHUBANESWAR,  GUWAHATI,  and VIJAYAWADA.

Services provided-

Elder Care, In-home Critical Care services, Diabetes Care, Physiotherapy treatment at home, Counselling, Nutrition and Diet Consultation, Laboratory Tests at home, Doctors'Consultation, new-born baby and mother care, and Medical  Equipment on rent or purchase.

COVID testing at home is available in Bangalore, Chennai, Delhi-NCR, Hyderabad, Kolkata,Mumbai and Pune in partnership with labs which are ICMR approved.

Elder Care-

Portea has comprehensive healthcare solutions as per individual requirements.

Eg: Portea Health Prime (starting at Rs. 5,000/- per annum) is an annual healthcare plan for elders in which every enrolled customer gets a dedicated Health Manager who will take care of all health requirements for the customer such as home visits by the doctor, lab tests, emergency care co-ordination etc.

Ph. 1800 121 2323

Website: www.portea.com

E-mail: customersupport@portea.com

2.  NIGHTINGALES - A Mahindra collaboration

Services available  in BANGALORE, HYDERABAD, MUMBAI, CHENNAI and PUNE

Services provided -

ICU Care at home, Elder Care, Diabetic Care, Routine Bedside Care, Post-operative Care,Stroke care, Short-term Nursing, Long-term Nursing, Caregivers, Physiotherapy, Speech and Language Therapy, Dental Care, Medical Equipment on rent, Sleep study, Laboratory Tests and Doctors'Consultation.

Salient features -

a) Over two decades of experience

b) Trained caregivers with pre-employment health check and background verification

c) Customised care

d) Continuity of care by providing replacements in case of leave or absence.

Ph. 1800 103 4530

Website: www.nightingales.in

3. INDIA HOME HEALTH CARE

Services available  in BANGALORE, CHENNAI, MUMBAI, PUNE, DELHI and NAGPUR.

It has been a home healthcare nursing services provider since 2009, in partnership with BAYADA - a home healthcare company headquartered in New Jersey, USA., which has a presence in 7 countries. 

The following categories of professional nursing services are provided at the patient's home-

a) ANM - Associate Nurse and midwife

b) Medical Caretaker (Male/ Female)

c) Registered Nurse

Services provided-

Elder care, Cancer care, Tracheostomy and ventilator care, Stroke rehabilitation, Cardiac care, Post-surgical care, Palliative care, Critical care, and Newborn care.

Elder care-

IHHC's Geriatric care program usually include services that are provided by medical caretakers which include the following-

Personal care, assistance with daily living activities, Companionship and emotional support, Specialist Alzheimers / Dementia care, Ongoing health monitoring  and Physiotherapy.

Ph: +91 7676433333

Website - www.indiahomehealthcare.com

4. HEALTH CARE AT HOME 

This organisation is a joint venture between the Burman family (promoters of Dabur) and the founders of Healthcare At Home (HAH) UK.

Services available in DELHI, MUMBAI, KOLKATA, and PUNJAB.

In BANGALORE, only COVID testing is available.

Services provided -

Physiotherapy services at home, Nursing services at home, Cancer care at home, ICU at home and Diabetes  Management program.

Home nursing services (12 and 24 hr. services) by experienced and certified staff

Home based critical care - Home ICU services with doctor-guided care plan and regular clinical audits

Home rehabilitation services for stroke recovery

Round the clock services for home delivery of medicines for most chronic conditions such as BP, Diabetes, Arthritis, Cancer, Kidney problems, and Thyroid.

Care Packages -

ICU at home; Cancer care at home; Stroke rehabilitation at home; Elderly care at home.

Ph. 1800 102 4224

E-mail: wecare@hcah.in

Website: www.hcah.in

5. APOLLO HOME CARE

Services available in HYDERABAD, CHENNAI, DELHI, BANGALORE and KOLKATA. 

Services provided-

Elderly Care, Physiotherapy, Home isolation, Renting of medical equipment, Nurse at home, Vaccinations , Investigations at home, Rehabilitation programs, and Mother and child care.

Elderly Care-

Regular home visits by physicians and physiotherapists, Personalised health records, Home delivery of medicines, Lab investigations, Ambulance services  to the nearest Apollo hospital.

Ph: 1800 102 8586

Website: www.apollohomecare.com

6. CARE 24

Services available in MUMBAI, DELHI-NCR, and BANGALORE

Home healthcare services provided -

Elder care, Attendant services by certified caregivers,  Home nursing services, Physiotherapy and rehabilitation services, Palliative care  and Infant care.

Ph:  Mumbai - 022-62820555; Delhi NCR - 011-61260555; Bangalore - 080-68248815

E-mail: support@care24.co.in

Website : www.care24.co.in

B- Organisations with a pan-Indian presence specialising in Elderly Care

1. LIFE CIRCLE SENIOR SERVICES

Services available in HYDERABAD,  BANGALORE,  DELHI - NCR,  CHANDIGARH TRICITY, and GUWAHATI.

Services provided -

Professional caregiving services and  home nursing services, 

Salient Features -

a) Service provided in partnership with GROUPE SOS, France

b) No minimum fixed contract period

c) Specialised caregivers for specific needs (such as Parkinson's, Alzheimer's, dementia, depression etc.)

d) Team based service

e) Vetted caregivers and home nurses

Ph:  Hyderabad - Bangalore : 040 71326832;  Delhi - NCR: 011 66765070;  

Chandigarh Tricity: 0172 6671070;  Guwahati : 011 66765070

Website: www.lifecircle.in

2. ELDER AID WELLNESS Pvt. Ltd.

Services available  in  BANGALORE,  KOCHI,  PALAKKAD and AHMEDABAD

Services Provided -

Complete at-home healthcare and wellness services -

 Nursing support, Healthcare support and Wellness and Concierge services

They have various packs priced differently, offering a bouquet of services, such as Emergency pack (at Rs. 1250/-p.m. +GST)  Comfort pack ((at Rs. 3990/- p.m.+ GST ) as well as a Pandemic support pack  (at Rs. 5990/- p.m. + GST). Customised packs are also available depending upon the specific requirements of the customer.

For example - their Emergency pack includes-

 One emergency assistance per year-  one house visit by the Care Manager for general health and well-being check-in, and  digital health check-up - medical history documentation and updation -regular telephonic check-ins

Ph. +91 8123400400

E-mail: info@elderaid.in

Website: www.elderaid.in

3 .EMOHA

This is India's first elder app with notifications for children. Various elderly care plans are available such as-

a) EMPOWER PLAN -a basic plan available all over India at Rs. 999 p.m. +18% GST (for upto 2 elders per household) which offers the following -

Regular phone calls and medication reminders  - 24*7 helpdesk - Emergency co-ordination - Interactive online activities - Electronic health records - Access to certified nurses and attendants for specialised home care (billed separately) - Access to specialised caregivers trained for dementia care, post-stroke rehabilitation and cancer support care,(billed separately)  co-ordinated and supervised by senior nurses (billed separately)

b) EMOHA ASSURE PLAN - available in Delhi-NCR at Rs. 6000/- p.m.

This offers additional features such as monthly home visit by a doctor - monthly home visit by a physiotherapist - Dietician calls twice a month - Personalised diet plans - 24*7 emergency response - 4 hr. support for household errands

c) EMOHA SMART HOME CARE PLAN - available in Delhi-NCR starting at Rs.800/- per day.

This is tailored to meet the requirements of elders requiring higher degree of personal care by certified caregivers who provide 12 hr. and 24 hr. home care nursing services.

Ph. 1800 203 5135; +91 9953354002

E-mail: eldersfirst@emoha.com

Website: www.emoha.com

4. ANVAYAA

Services available in HYDERABAD, BANGALORE and CHENNAI

Services provided -

a) Healthcare Assistance - It has partnered with doctors, healthcare professionals, diagnostic and pharmacy outlets to provide various forms of senior healthcare services at home.

b) Daily Care - It has partnered with  home maintenance service providers, transport providers, food and maid service providers to provide various kinds of domestic help services at home.

c) Leisure care - Care managers will provide assistance in organising family events, arranging picnics, day outings etc.

d) Payment care - Provides help with payment of utility bills and managing medical emergencies through prepaid medical wallet facility.

e) Emergency care - Providing ambulance assistance, real-time updates to family members etc.

f) Other services - Arranging health and travel insurance services, religious services, legal services, property management services and travel assistance.

Ph. +91 7288818181 / 9392682922

E-mail: connect@anvayaa.com

Website: www.anvayaa.com

5. TRIBECA CARE

Services available in KOLKATA, HOWRAH, KALYANI, and BHUBANESHWAR.

Services provided -

Elder care, Home nursing services by medically trained nurses, Physiotherapy services, Home security services  ( CCTV and home surveillance systems), Medical equipment on rent and Assisted living facilities.

Elder Care -

24*7 emergency response helpline, Trained nurses and attendants, Home diagnostics, and Assisted tele medicine platform to connect on video calls with doctors with the help of Care Managers.

Home delivery of medicines and groceries, Banking assistance.

Ph. +91 3366064208

E-mail: enquiry@tribecacare.com

Website: www.tribecacare.com

6. ELDER CARE

Services available in DELHI, BANGALORE, PUNJAB, CHANDIGARH, HARYANA and UTTARAKHAND.

This has been set up by a team of doctors, physiotherapists, counsellors and retired personnel from the Indian Armed Forces.

Services provided -

1) Healthcare services - Physiotherapy, Trauma and critical care, Illness and post-hospitalisation care, Yoga and ayurvedic services.

2) Financial services - Filing IT returns, Banking related services, Payment of utility bills, Wealth management.

3) Property services - Rent/ purchase / sale, Management of agricultural land, Inspection and site visits.

4) Miscellaneous services for NRIs visiting  parents

5) Legal services

Ph. +91 9810027950 /  7303699880

E-mail: info@eldercare.co.in

Website: www.eldercare.co.in

PALLIATIVE CARE CENTRES IN INDIA

 INTRODUCTION

It was gratifying  to note that my previous post on palliative care in India evoked a positive response. Many readers wrote in to say that they found the post very useful and informative on a relatively unknown topic. As a logical  follow-up to that post, the current post features  a listing of palliative care centres  in some of the major cities in India. The cities covered include the following: 

a) SOUTH 

KERALA - Trivandrum, Ernakulam, Thrissur,  and Kozhikode  

KARNATAKA - Bangalore

TAMIL NADU - Chennai

ANDHRA PRADESH - Hyderabad

b) WEST

MAHARASHTRA- Mumbai, Pune

GUJARAT- Ahmedabad

c) EAST

WEST BENGAL - Kolkota

d) NORTH

DELHI

                                           

                                                                      KERALA 

I. TRIVANDRUM

1.  Pallium India,  Trivandrum.

     Provides compassionate, high quality palliative care, bringing support and relief to 

     those in pain through its network of care centres. 

    Address: PJRRA 65, Pothujanam Road, 

    Medical College P.O. TRIVANDRUM- 695011.

    Ph. +91 9746745497, +91 9387296889

    Website:www.palliumindia.org

2.  Trivandrum Institute of Palliative Science (TIPS)

     It is a WHO collaborating Centre for Training and Policy on Access to Pain Relief. 

    It runs a clinical service developing and operating community oriented palliative care 

    services including the service of local volunteers and home visits.

    Address: Airport Road, Subash Nagar, 

    Vallakadavu P.O. TRIVANDRUM -695008 .

    Ph. +91 9746745497, +91 9387296889

    Website: www.palliumindia.org

3.  TIPS Pain and  Palliative Care Clinic, Trivandrum.

      It has an in-patient palliative care unit, a  palliative care out-patient clinic 

      and hospice home care service.

    Address: TC 2/2504, Vrindavan Housing Colony, 

    Near SUT Hospital, Pattom, Trivandrum.

    Website: www.palliumindia.org

4. Regional Cancer Centre, Trivandrum

    In-patient palliative care unit, palliative care out-patient clinic and hospice 

    home care service.

    

    Address: Medical College Campus, Chalakkuzhi,Trivandrum - 695011.

    Website: www.rcctvm.org

5. Sukrutham Palliative Care Clinic, Trivandrum.

    Address: Vineeth Library, Muttacaud P.O. Trivandrum - 695523.

II - ERNAKULAM

1. Amrita Institute of Medical Sciences, Kochi.

    With a dedicated team of physicians, nurses and other healthcare professionals, it 

    provides the full range of primary and specialty care medical services.

    Address: Ponekkara P.O.,Kochi -682041.

    Website: www.amritahospital.org 

2. Anwar Memorial Pain and Palliative Care Society, Aluva

    With support from the Indian Red Cross Society, Aluva, and Kerala Action Force, it

    seeks to improve the quality of life to patients with incurable diseases and  old age 

    ailments, through total care for them and their families.

    Website: www.anwarpainandpalliative.org 

3. Lakeshore Hospital and Research Centre, Department of Pain and 

    Palliation, Ernakulam

    The palliative care team is available to patients and their families in the case of 

    life-threatening illnesses.

    Address: NH 47 Byepass, Nettoor, Maradu, Ernakulam - 682040.

    Website: www.lakeshorehospital.com

4. The Palliative and Cancer Care Clinic, Kochi

    Homeopathic multi- specialty centre for the preventive, curative and  palliative treatment of cancer.

    Address: German Medical Centre for Homeopathy, Koonamthai, Kochi-682033.

    Website: www.thepalliativecare.in

5. Rajagiri Hospital, Kochi

    Address: Chunangamvely, Aluva - 683112.

    Website: www.rajagirihospital.com

    

6. Karunya Pain and Palliative Care Clinic, Ernakulam

    Address: Health Care Charitable Society, Thiruvankulam P.O.

7. Peace Mission Centre, Aluva.

Launched by the Guardian Angel Care Charitable Society, it provides specialised medical and nursing care for people with terminal illnesses, the goal being to improve the quality of life for both the patient as well as the family. Care services are provided free of cost,  in the form of home care as well as in-patient care.

   Address: Mekkad P.O., Thuruthissery, Nedumbassery, Aluva - 683589

   Ph. 0484 2477083,  0484 2477183.

III - THRISSUR

1. Alpha Palliative Care, Thrissur

    Provides holistic support to patients dealing with life-threatening illnesses by 

    providing medical services as well as psychological, social, practical and spiritual 

    support within the family and home environment.

    Address: Pottayil Lane, M.G.Road, Thrissur. 680568.

    Website: www.alphapalliativecare.org 

2. Ansar Hospital Pain and Palliative Care Clinic, Thrissur

    Has a palliative care out-patient clinic and hospice home care service.

    Address: SH69, Ansar Nagar, Perumpilavu, Karikkad, Thrissur - 680519

    Website: www. ansarhospital.com

3. Pain and Palliative Care Society, Thrissur

    It has an out-patient clinic, in-patient clinic, home care service, a physio-therapy 

    unit and a training centre for palliative care teaching and training for doctors and 

    nurses.

    Address: Institute of Palliative Care, Thrissur, Old District Hospital Building, 

    Thrissur - 680001.

    Website: www.painandpalliativecarethrissur.org.

4. Palliative Care Unit, West Fort Hi-Tech Hospital, Thrissur

    Provides total care for terminal stage cancer patients and patients of other 

    life-threatening illnesses.

    Address: Punkunnam, Thrissur - 680002.

    Website: westforthospitalgroup.org

5. Thrissur Pain and Palliative Care Society

    Caters to the care and support of patients having life-threatening diseases, 

    as well as their families.

    Address: Thrissur, Swaraj Round E, Thrissur - 680001.

    Website: www.painand palliativecarethrissur.org

IV- KOZHIKODE

1. Institute of Palliative Medicine (IPM), Kozhikode.

    IPM is instrumental in developing the "Kerala Model" of palliative care which is 

    popular among the palliative care fraternity worldwide. It is the training, research and 

    outreach arm of the Pain and Palliative Care Society (PPCS).

    Address:  Institute of Palliative Medicine, Medical College P.O. Kozhikode - 673008.

    Website: www.instituteofpalliativemedicine.org

2. Pain and Palliative Care Clinic, Kozhikode.

    Address: Medical College, Kozhikode.

    Website: www.painandpalliativecare.org

                                                                

                                                        KARNATAKA

BANGALORE 

1. Bangalore Hospice Trust - Karunashraya 

    A registered charitable trust set up by The Indian Cancer Society (Karnataka Chapter) 

    and Rotary Bangalore Indira Nagar, to provide free professional palliative care for 

    advanced stage cancer patients.

    Address: Old Airport Varthur Main Road, Kundalahalli Gate, Marathahalli, 

    Bangalore - 560037.

    Website: www.karunashraya.org

2. Kidwai Memorial Institute of Oncology - Dept. of Palliative Care, 

    Bangalore.

    Provides primary symptom care with a multi-disciplinary team.

    Address: Dr. M.H.Marigowda Road, Bangalore - 560029.

    Website: www.kidwai.kar.nic.in;  www.kmio.org

3. Manipal Hospital, Bangalore.

    Has a Dept. of Radiation, Oncology and Palliative Medicine.

    Address: 98, HAL Airport Road, Bangalore - 560017.

    Website: www.halairportroad.manipalhospitals.com

4. St. John's Medical College - Dept. of Palliative Care, Bangalore.

    Address: Sarjapur Road, Bangalore - 560034.

    Website: www.stjohns-hospital.com

                                                                     TAMIL NADU

CHENNAI

1. DEAN Foundation Hospice and Palliative Care Centre, Chennai.

    Provides home care and out-patient care from two of their centres: 

    Kancheepuram and Karamadai, Coimbatore. 

    It has a Paediatric Palliative Care ward at the Institute of Child Health and Hospital for 

    Children,  Chennai.  Also provides palliative care to patients at the Institute of 

    Obstetrics and Gynaecology, located in the same campus. No mandatory fees 

    are charged. 

    Address: Old No. 73/New No. 59,  2nd Street, Aspiran Garden Colony, 

    Chennai - 600010.

    Website: www.deanfoundation.org

    E-mail: deanfn@gmail.com

    Ph. +91 9444924949  

2. Jeevodaya Hospice India, Chennai

    Renders palliative care services free of cost to advanced cancer patients .

    Address: 1-272 Kamaraj Road, Chennai .

    Website: www.jeevodaya.blogspot.com.au

3. Karuna Sagar Hospice, Chennai.

    Provides hospice and palliative care services.

    Address: Kallurisalai, Kolathuvanchey, Paraniputhur Mangadu, Chennai- 602101.

    Website: www.rmdpainpalliative.com

4. Lakshmi Sundaravadanan Hospital - Lakshmi Pain and Palliative Care 

    Trust, Chennai.

    Out-patient clinic, In patient care, home visits and Lymphoedema Clinic.

    Address: No.134, Poonamalle High Road, Chennai -600084.

    Website: www.lakshmitrust.org

    E-mail: lakshmipaincare@gmail.com

5. Palliative Care Unit, Christian Medical College & Hospital, Vellore.

    Website: www.cmch-vellore.edu

6. RMD Pain and Palliative Care Centre Unit, Chennai.

    Out-Patient and In-Patient palliative care.  Also specialised palliative care for 

    the elderly.

    Address: 13, Raghaviah Road, T Nagar, Chennai - 600017.

    Website: www.rmdpainpalliative.com

7. Unit II - Karuna Sagar Hospice, Chennai

    Address: Kolathuvanchey, Paraniputhur, Chennai - 602101.

    Website: www.rmdpainpalliative.org

                                                                   ANDHRA PRADESH

HYDERABAD

1. MNJ Institute of Oncology & Regional Cancer Centre, Hyderabad

    Out-patient care, in-patient care and home based care for patients in the twin cities of 

    Hyderabad and Secunderabad, with the help of an NGO.

    Address: Red Hills, Lakidikapul, Hyderabad - 500004.

    Website: www.mnjiorcc.org

2. Pain Relief Palliative Care Society, Hyderabad.

    Supports the palliative care program at MNJ Institute of Oncology, Hyderabad.  

    Offers out-patient  care, in-patient care and home based care for patients in 

    Hyderabad and Secunderabad. It is also one of  the leading centres for training, 

    advocacy and research for palliative care in the country.

    Address: Pain Relief and Palliative Care Society, Kumudini Devi Palliative Care 

    Centre, No. 1-6,  New Vivekananda Nagar Colony,  Kukatpally, Hyderabad - 500072.

    Website:www.palliativecarepartners.in

3. Sparsh Hospice Centre for Palliative Care, Hyderabad.

    Promoted by the Rotary Club of Banjara Hills Charitable Trust, Sparsh takes care of 

    terminally ill patients , typically in the last stages of cancer. All services are provided 

    free of cost.

    Address: Plot No. 85, 8-2-703/2/1, Road No. 12, Banjara Hills, Hyderabad - 500034.

    Website: www.sparshhospice.org

    E-mail: info@sparshhospice.org

    Ph. 04023384039

                                                        MAHARASHTRA

MUMBAI

1. TATA Memorial Hospital Palliative Care Clinic, Mumbai.

    It is a part of the TATA Memorial Centre, which is the national comprehensive cancer 

    centre for the prevention, treatment, education and research in cancer.

    Address: Dr. E Borges Road, Parel, Mumbai - 400012.

    Website: www.tmc.gov.in

2. Shanti Avedna Sadan Hospice, Mumbai.

    It is India's first hospice  - an institution that takes care of the advanced terminally-ill 

    cancer patients. It is entirely a non-governmental voluntary organisation, run by 

    a charitable trust.

    Address: 216, Mount Mary Road, Bandra West, Mumbai - 400050.

    Website: www.shantiavednasadan.in

3. Caregiver Saathi , Mumbai.

    It is an endeavour to acknowledge and support caregivers of patients with terminal 

    illness or chronic conditions by providing care, emotional support, understanding, 

    easy access to information and guidance from experts.

    Address: A4104, Oberoi Exquisite, Goregaon East, Mumbai 400063.

    Website: www.caregiversaathi.co.in

4. Cancer Patients Aid Association (CPAA) - Mumbai.

    It is a registered charitable NGO working towards the total management of cancer 

    as a disease.

    Address: Dr. E Moses Road, Mahalaxmi, Mumbai - 400011.

    Website: www.cpaaindia.org

5. Bhaktivedanta Hospital & Research Institute, Thane.

    Provides in-patient care, out-patient care,  home care, spiritual and psychological 

    counselling. It caters to patients in the western suburbs of Mumbai from Borivali to 

    Virar and beyond.

    Address: Shrishti Complex, Bhaktivedanta Swami Marg, Mira Road (East), 

    Thane - 401107.

    Website: www.bhaktivedantahospital.com

PUNE

1. Care India Medical Society, Pune.

    It provides a social support system for the prevention, early detection and 

    terminal care aspects of  cancer control management.

    Address: 4/22, Veer Bharat Society, Bhawani Peth, Pune - 411042.

    Website: www.cimspune.com

    E-mail: fatimalilani@gmail.com

    Ph. +91 2026450093.

2. CIPLA Cancer Palliative Care & Training Centre, Pune.

       Provides holistic palliative care for cancer patients by following a family care model. 

       All medicines and services are provided free of cost.

    Address: Off Mumbai- Bangalore Bypass Road, Warje, Pune - 411058.

    Website: www.carebeyondcure.org

                                                   GUJARAT

AHMEDABAD

1. Apollo CBCC Cancer Care, Ahmedabad.

    It is a joint venture of Apollo Hospitals International Ltd. and Amrish Oncology 

    Services Pvt Ltd., a company promoted by California based Comprehensive Blood and 

    Cancer Centres.

    Address: Akshara Complex, 12, Shanti Sadan Co-op Housing Soc. Ltd. 

    Near Parimal Garden, Ahmedabad - 380006.

    Website: www.apollocbcc.com

    Ph. +91 7940734073

2. Department of Pain & Palliative Medicine, Ahmedabad.

    The institute has OPD, in-patient, hospice and home-care services for cancer patients 

    needing  palliative care.

    Address: Civil Hospital campus, Asarwa, Ahmedabad - 380016.

3. Gujarat Cancer & Research Institute,  Dept. of Pain & Palliative Medicine, 

    Ahmedabad.

    One of the largest cancer care centres of the country, it has OPD, in-patient, 

    hospice and home-care services for cancer patients needing palliative care.

    Address: Civil Hospital Campus, Asarwa, Ahmedabad - 380016.

    Website: www.gcriindia.org/palliative_medicine

    Ph. +91 9825420656

4. Karunalay Cancer Palliative Care Centre, Ahmedabad.

    It was set up by Shyam Oncology Foundation to provide palliative care to needy 

    cancer patients.

    Address: Shivranjani Cross Roads, Ahmedabad - 380015.

    Website: www.shyamoncologyfoundation.org

                                                                 WEST BENGAL

KOLKATA

1. Kolkata Medical College & Hospital

    It has an Out-patient Palliative Care Clinic.

    Address: Dept. of Radiotherapy, 88 College Street, Kolkata.

    Website: www.medicalcollegekolkata.org

2. Fortis Hospital, Anandapur, Kolkata.

    The Fortis Centre for Pain & Palliative Care addresses the medical, physical and 

    psychological  aspects of pain management to patients suffering from acute and 

    chronic disabling pain disorders.

    Address: 730, Anandapur, E M Bypass Road, Kolkata - 700107.

    Website:www.fortishealthcare.com

3.  Chittaranjan National Cancer Institute, Kolkata.

    Address: 37, Shyama Prasad Mukherjee Road, Bhawanipur, Kolkata - 700026.

    Website: www.cnci.org.in

4. Dept. of Palliative Care & Psycho-oncology, Tata Medical Centre, Kolkata.

    Holistic care is provided to all the patients at Tata Medical Centre through early

    integration of palliative care with cancer care through out-patient care and 

    in-patient admission.

    Address: Tata Medical Centre, Major Arterial Road, New Town, Kolkata.

    Website: www.tmckolkata.com

    E-mail: shrikant.atreya@tmckolkata.com

                                                               DELHI

DELHI

1. CanKids.....KidsCan, New Delhi.

    Provides palliative care and support services for children with cancer (age 0 to 21) and 

    their families from the time of diagnosis through treatment and afterwards into 

    survivorship on the one hand and  palliative care, terminal and bereavement support 

    on the other.

    Address: J-161/A, Gautam Nagar, New Delhi.

    Website: www.cankidsindia.org

2.CanSupport, New Delhi.

    Provides a wide range of services designed for cancer patients of all ages at all 

    stages of cancer.  Palliative care services are offered free of charge, and focuses on 

    keeping the patient pain free to be  able to enjoy a good quality of life.

    Address: A-2, Gulmohar Park, Opp. Kamala Nehru College, New Delhi.

    Website: www.cansupport.org

    E-mail: info@cansupport.org

    Ph. +91 11 41010537/38

3. DNIPCare - Delhiites - National Initiative in Palliative Care

    Works towards the development of a sustainable, cost-effective system of palliative 

    care with active community participation, for patients suffering from incurable life

    limiting diseases including cancer.

    Address: 83, Akriti Apartments, 62, IP Extension, Delhi - 110092.

    Website: www.dnipcare.org

4. Emmanuel Hospital Association, Dept. of Palliative Care.

    It is a large non-profit provider of health care in India, with a network of 20 hospitals 

    and 42 projects spread across 12 states of India. It operates palliative care services at 

    8 locations, including one at Shalom Delhi.

    Address: EHA, 808/92, Deepali Bldg., Nehru Place, New Delhi - 110019.

    Website: www.eha-health.org

5. Rotary Cancer Hospital Pain Clinic, New Delhi.

    Address: IRCH, AIIMS Campus, Ansari Nagar East, New Delhi - 110029.

    Website: www.aiims.edu

6. Shanti Avedna Sadan Hospice, New Delhi.

    It is a non-governmental voluntary organisation  run by a charitable trust, which takes 

    care of  advanced terminally ill cancer patients. 

    Address: 1- Factory Road, Near Safdarjung Hospital, New Delhi.

    Website: www.shantiavednasadan.in

7. Venkateshwar Hospital, New Delhi.

    A super specialty hospital with a complete medical oncology section, including a 

    Pain and Palliative Care department.

    Address: Sector 18A, Dwarka, New Delhi - 110075.

    Website: www.venkateshwarhospital.com

    Ph. +91 9818432332

PALLIATIVE CARE IN INDIA

Introduction
In my previous post on 'Living Will in India',  I had briefly touched upon the concept of palliative care, and its relevance for meaningful execution of a living will. However, to many readers, the concept of palliative care was somewhat unfamiliar and some even requested  that I should write a more comprehensive post on the subject for a better understanding and appreciation of the concept.

What is Palliative Care
The goal of palliative care is to improve the quality of life of  persons with serious illnesses and their families, by responding to physical pain, other distressing physical symptoms as well as by providing nursing care, psycho-social and spiritual support. A serious illness affects more than just the body. It affects all areas of a person's life, as well as the lives of his/her family members. This is why palliative care  would best be administered by an inter-disciplinary, multi-dimensional team comprising doctors, nurses, counselors, social workers and volunteers. Palliative care specialists take care of people with many disease types and chronic illnesses, including cancer, cardiac diseases, kidney failure, Alzheimer's, Parkinson's and many more. Palliative care can be given along with treatments meant to cure or treat the disease. It may be given when the illness is diagnosed,  throughout the treatment , during follow-up and towards the end of life.

Palliative Care in India
It is estimated that in India, the total number of people who need palliative care is likely to be 5.4 million a year. Kerala has been the pioneer for offering excellent palliative care in India.  The government of Kerala has, through  formal policies, facilitated the provision of palliative care through the public health system. The state now has around 1550 palliative care units, 450 of which are run by community based organisations and NGOs.

Kozhikode is where it all started in 1993, when doctors at the Govt. Medical College led by Dr. M.R. Rajagopal and Dr. Suresh Kumar founded the Pain and Palliative Care Society (PPCS) which now runs the Institute of Palliative Medicine in the city. Starting out with focus on cancer, it was recognised by the WHO in 1995, and has expanded its scope over time. But the real turning point came in 1999-2000 when they started Neighbourhood Networks in Palliative Care (NNPC) - an approach that emphasised local, community based care, rather than an institutional , hospital-based approach led by doctors. Since 2000, the NNPC has trained volunteers from the local community to identify problems of the chronically ill in their area and to intervene effectively, with active support from a network of trained professionals.

A palliative care institution undertakes three basic programmes: Out-Patient clinic, Home Care and In-Patient clinic/ Hospice care. Initially, the patient is registered at the out-patient clinics, and depending on the location, he/she is linked with the home-care services. Home based palliative care services are becoming increasingly popular, with care being taken to the door-step of the patient. Ideally, this is where people are most comfortable at the end of their lives, surrounded by their loved ones. It is also one of the few ways that patients in rural areas, where healthcare facilities are inadequate,  can access palliative care. Out- patient services facilitate all aspects of palliative care for patients and their families , while hospice care  is recommended for the management of difficult symptoms requiring expert management and end of life (terminal stage ) management.

Services offered by out-patient clinics and professional home care units include medical support in the form of consultations, providing medicines and undertaking minor procedures such as wound care. NNPC groups also offer emotional support to patients, food for needy patients and their families, educational support to their children, transportation to the hospital when required and social rehabilitation programmes, in addition to the medical and nursing services. By placing emphasis on community based and home care services, palliative care can reduce the costs associated with emergency hospitalisation and prolonged hospital stays.

Pain relief is a very important component of palliative care, especially in the treatment of cancer. The availability of morphine, a scheduled drug essential for pain management in serious cases, used to be a challenge in providing meaningful palliative care services in India. Due to earlier stringent regulations, the availability of morphine was severely restricted across the country, subject to rules laid down by the Narcotics, Drugs and Psychotropic Substances Act of 1985. Following an amendment to the Act in 2014, morphine and similar opioid pain medications are now made available for clinical use by licensed practitioners providing much needed relief to suffering patients.

Conclusion
Only 2% of the population who need palliative care in India have access to it, far below the global average of 14%. The dismal state of palliative care in India makes the country one of the worst places to die in. The Economist Intelligence Unit's (EIU's) Quality of Death Index 2015 places India at the 67th position among the 80 countries that were surveyed, behind countries like Kenya, Peru and Ecuador.While Kerala, and in recent years, other southern states such as Karnataka, have made substantial progress in the field of palliative care, much remains to be done elsewhere in the country.

THE LIVING WILL AND PALLIATIVE CARE IN INDIA

Introduction
In a landmark judgement in March 2018,  the Supreme Court  of India held that the right to die with dignity was part of the right to life under the Constitution as a fundamental human right.This has been made possible by legalising "Passive Euthanasia", by allowing individuals to prepare an "Advance Medical Directive" or a "Living Will"  to refuse medical treatment in the event of being terminally ill or in a persistent vegetative state. However, a year after the judgement, a survey of more than 2400 urban Indians across seven cities - Delhi, Mumbai, Kolkata, Hyderabad, Bangalore, Chandigarh, and Jaipur - revealed that only 27% were aware of the concept of a Living Will.

What is a Living Will
A living will / Advance Medical Directive is a legal document that specifies a person's wishes regarding medical treatment; specifically treatments that will prolong life. This document is prepared in advance, well before it is actually needed and is used when a person is unable to make medical decisions for himself/herself due to his/her medical condition.
The concept of a living will, while upholding the right to die with dignity as a fundamental right, also has the following advantages-
a) It helps medical professionals to take difficult decisions and
b) It frees a patient's family from the guilt of having to take difficult decisions.
At the same time, in order to guard against the danger of misuse, the Supreme Court has laid down detailed guidelines relating to the preparation of the living will, as well as elaborate  safeguards for execution of the living will to give effect to passive euthanasia.

Guidelines for the preparation of a Living Will
1. It should be a written document made voluntarily by the person (and not under duress) who should be of a healthy and sound state of mind with the capability to communicate his/her intent clearly.
2.It should contain a declaration that the person making it is aware of the consequences of executing the will.
3. It should mention that the executor may revoke the instructions at any time.
4.  It should state clearly  -
a) at which point in time treatment should be withdrawn
b) the circumstances of enforcing such a decision
c) the name of the relative who can decide on his/her behalf
5. It should be signed by the person making it in the presence of two witnesses, and countersigned by the jurisdictional Judicial Magistrate of First Class (JMFC) confirming that the will has been drawn up voluntarily.
The JMFC will maintain a copy of the will and forward a copy to the registry of the district court of that jurisdiction.
Another  copy has to be handed over to the nominated official of the municipal  corporation for safe custody.
Further, the  JMFC also has to hand over a copy of the directive to the family physician.

Execution of the Living Will
When a person becomes terminally ill, with no hope of recovery despite treatment, the treating physician, when made aware about the living will, has to ascertain the genuineness and authenticity of the document from the JMFC, after which all the proper legal and operational procedures laid down to give effect to the living will must be followed.
a) A  preliminary opinion has to be sought from a duly constituted hospital medical board which has to give their permission for the execution of the living will.
b) The hospital then has to inform the jurisdictional Collector about the clearance from the medical board.
c) The Collector shall constitute another medical board chaired by the Chief District Medical Officer who will convey the decision of the board to the jurisdictional judicial magistrate.
d) The judicial magistrate shall visit the patient at the earliest, and after examining all aspects, authorise the implementation of the Board's decision.

In cases where the medical board refuses to grant permission to execute the living will, the family will have to approach the High Court to decide upon the case.

As is evident from a perusal of the complex legal and operational  checks and balances that have been laid down, from a practical point of view, the execution of a living will in India is easier said than done, thereby creating legal uncertainty around end of life decision making. This has emerged as a barrier in ensuring the quality of death and the right to die with dignity. As a result, terminally ill patients often spend their last days in Intensive Care Units in a bid to artificially prolong life at high emotional and financial costs to them and their families.

Authorities as well as those keen to register a living will are struggling in the absence of standard procedures at the central or state levels to implement the SC guidelines. Lack of legal certainty and fear of prosecution often prevents doctors from making ethically sound decisions on end of life care. The practical difficulties have triggered a demand from stakeholders for a comprehensive law on end of life care which would simplify the required protocols. Meanwhile, leading hospitals such as AIIMS Delhi have framed their own internal policies and the ICMR has developed guidelines for health professionals on "Do Not Attempt Resuscitation Orders".

Lastly, for the living will to be operationally meaningful, it is extremely important to have adequate palliative care facilities, which are woefully inadequate in the country.

Palliative Care
According to the WHO, palliative care is a multi-disciplinary approach that improves the quality of life of those patients suffering from life-threatening illnesses and also their families, by relieving suffering and pain - physical, psycho-social and spiritual. Although palliative care is a broad concept which can be provided at various stages of an illness, it is most closely associated with end-of-life care.

In the world of palliative care, practitioners distinguish between a "good death"and a "bad death."A good death is one where the patient dies peacefully, without pain, in the presence of loved ones and often, at home. A bad death is one where the patient dies alone, often in unbearable pain, typically after having his / her life prolonged by aggressive and dehumanising care, usually in an ICU. The palliative approach looks not just at difficult symptoms of an illness, but also on the overall benefits/side effects of possible treatments and the emotional, physical and financial stresses for patients and their families.

Palliative Care in India
The state of palliative care in India at present is quite dismal, making the country one of the worst places to die in. The Economist Intelligence Unit's (EIU's) Quality of Death Index 2015,  which analysed the quality of palliative care facilities around the world, places India at the 67th position among the 80 countries that were surveyed, behind countries like Kenya, Peru and Ecuador.

As per recent statistics, only 2% of the people who need palliative care in India have access to it, far below the global average of 14%. Even the availability of morphine as a painkiller, despite a 2014 amendment to the Narcotic Drugs and Psychotropic Substances Act 1985, has been a major problem hampering improvements in end-of-life care.

In comparative terms, the southern states of Kerala, Karnataka and Tamil Nadu are at the forefront of providing end-of-life care, as over 90% of the palliative care centres are located in these three states. The Institute of Palliative Medicine , Kozhikode, was one of the earliest palliative care centres in the country. Started in 1993, the Centre does not limit itself to providing palliative care to patients, but has also made a significant contribution to the important issues of policy making and generating awareness about this concept which has assumed significance in the light of the recent Supreme Court ruling legalising  passive euthanasia through the living will .What started in Kerala, is now gradually trickling to other parts of the country as well.

MAKING A WILL

INTRODUCTION

Having worked hard at creating wealth during one's lifetime, it is equally important that you decide what happens to your accumulated wealth after you are gone. For this, you need to have a wealth succession plan in place. What is the best way to do this? The smoothest way is to leave behind a will to ensure that the final allocation of your wealth happens according to your wishes.

WHAT IS A WILL?
A will is a legal document that names the individual/individuals who would receive the property and possessions of a person after his/her death. Any person with a sound mind and who is not a minor can bequeath his/her property with the help of a will.The document can be revoked, modified or substituted by the person executing it at any point during his/her lifetime.

IMPORTANCE OF WILL PLANNING
If a person dies intestate (without making a will) ,his/her assets will be divided and distributed according to the succession laws, which are based on the religion of the deceased person. In the absence of a will, the legal heirs would have to incur substantial expenses to acquire mandatory documents like a succession certificate or letter of administration, in order to transfer titles, cash investments, assets or properties, apart from the prohibitive legal fees involved. A succession certificate is required in the case of movable properties, while the letter of administration is needed in the case of immovable property.
Will planning is important because the document always acts as an inventory of the assets left behind by the deceased. A will also helps in avoiding any conflict among the natural heirs.Moreover, if a person wants to distribute his/her wealth to anybody other than the natural heirs, the will assumes paramount importance

TYPES OF WILLS
There are two types of wills - Privileged Will and Unprivileged Will.
A Privileged Will is an informal will which can be made either in writing or also by an oral declaration and at short notice by individuals who are about to put their life at risk, such as soldiers , airmen or sea mariners engaged in warfare.
All other wills are called Unprivileged Wills which require formalities to be followed.

REGISTERING THE WILL
 You can make your will on your own on a piece of paper ensuring that all the important details and requirements are in place, to avoid any dispute. There are several templates available online, which can serve as a guide to drafting the will by yourself. Since no stamp duty is payable on a will, it need not be written on stamp paper. However, if you have several assets that require clarity, or if your estate is worth a lot of money, it is best to hire the services of a lawyer who will be able to draft your will clearly, avoiding ambiguities that can result in legal battles.
In India, registering of wills is not compulsory, even if it relates to immovable property.However, registering a will can put an end to any doubts about its authenticity.
A will can be registered with the Registrar / Sub- Registrar at a nominal registration fee. Once a will is registered, the sealed envelope containing the will and superscribed with the name of the testator (the person making the will) or his agent,  is placed in the safe custody of the Registrar and cannot be tampered with, destroyed, mutilated or stolen.

REQUIRED FORMALITIES FOR AN UNPRIVILEGED  WILL
1) The signature or mark of the testator  is necessary for an unprivileged will. Although in certain situations, the will may be signed by some other person in the presence of the testator, it is always advisable to have a will signed by the testator, in order to avoid any dispute later.
2) Every unprivileged will should be attested by atleast two witnesses who have seen the testator or his agent sign it, and who should sign the will in the presence of the testator.For a will to be valid, the beneficiary under a will should not be a witness.
3) Apart from the testator and the beneficiaries, a will should also have an Executor who is entrusted with the responsibility of transferring the property as desired by the testator.The executor can be any person who is not a beneficiary in the will. If there is no executor for a will, the court will appoint one.
4) It is important for the will to include  the following three declarations -
a) that you are revoking all earlier wills
b) that you are of sound mind
c) that you are not making the will under any pressure.

SOME OTHER USEFUL POINTS TO KEEP IN MIND
1) Make your will as specific as possible. If any detail is not precise or you get it wrong, the will can be easily contested in court.
a) List all assets in detail - mention bank account number(s), locker number, and details of property, both movable and immovable.
Specify PAN Number in the case of mutual fund investments, since all mutual fund folios are linked to the PAN Number.
b) In the case of beneficiaries, mention the full name, your relationship with the person, and the assets you want to give. Moreover, identify each beneficiary with their Aadhar number, PAN Number or OCI number (in the case of NRIs)

CODICIL
If there is any alteration in the status of assets or heirs, such as sale of existing assets or purchase of new assets, these changes can be incorporated in the original will through a Codicil.
 In India, a codicil is an addition to your original will, which basically states what items of your will you are changing. For it to be valid, you will have to follow the same procedures as when you created the original will.
However, if you are making substantial changes to your will, it would be advisable to draft a new will, including a declaration that it is your final will and revoking all previous wills and codicils.
As per law, the last drawn will is considered, whether registered or not.

GIFT DEED
A gift deed is a document that records the act of giving a gift and is executed between the Donor (the person giving the gift) and the Donee (the person receiving the gift). It takes effect during the lifetime of the donor. A gift can be movable or immovable property that is transferable and tangible. Gifts that involve immovable property should be registered under the Indian Registration Act. Stamp duty is payable based on the value of the gift, ascertained by approved valuation experts. Gifts made to relatives as defined by the Income Tax Act are exempt from tax in the hands of the donee.

WILL vs GIFT DEED
1) A gift deed operates as soon as it is executed and the asset(s) gifted will vest in the donee during the lifetime of the donor. On the other hand, a will is operative only on the death of the testator. Therefore, properties bequeathed through a will can vest in the beneficiaries only after the death of the testator.
2) A will, whether registered or not, can be revoked during the lifetime of the testator. On the other hand, a gift deed, once executed, is irrevocable.
3) A will does not require to be stamped or registered, but a gift deed requires to be stamped as per applicable stamp laws.

The  Supreme Court ruling in March 2018 now allows for the creation of a Living Will which sets out a person's wishes on how they want to be treated if they are seriously ill and and become unable to communicate their decisions. More on this in my next post.