Reflections on the ICMR 2020 Consensus Guidelines on Do Not Attempt Resuscitation

The Indian Council of Medical Research (ICMR) released its much-awaited Consensus Guidelines on Do Not Attempt Resuscitation (DNAR) in 2020.^[1,2] These guidelines were welcomed by the medical community as they addressed a long-standing dilemma faced by physicians in India. Until the release of this landmark policy document, DNAR had no formal recognition in India, despite its established practice both nationally and internationally. In many developed countries, DNAR is practiced with clear legal backing. The ICMR guidelines thus provided much-needed regulatory direction and legitimacy to DNAR decision-making in India. Before 2020, Indian physicians lacked a standardized protocol for DNAR orders, resulting in inconsistent practices and ethical uncertainty. Many physicians performed cardiopulmonary resuscitation (CPR) in situations where it was futile, causing injury and prolonging suffering in patients unlikely to regain a reasonable quality of life. Physicians aware of CPR futility often resorted to slow codes to avoid discussing the matter with patient surrogates or facing legal repercussions. Many clinicians, even after discussing DNAR with families, were uncertain about subsequent management, sometimes withdrawing all care due to the misconception that no further treatment was warranted. The ICMR guidelines clarified that DNAR applies solely to CPR and that physicians must continue providing appropriate curative and supportive care with compassion.

A significant milestone was the introduction of a standardized DNAR form, previously absent in Indian clinical practice. Earlier, physicians used improvised, suboptimal documentation lacking the required patient details. The new standardized form ensures uniform documentation and minimizes ambiguity. Importantly, the guidelines distinguish the roles of the physician and surrogate decision-makers, emphasizing shared decision-making, clear communication, and maintenance of patient dignity.

The guidelines also include a patient information sheet pro forma for hospitals to integrate into their policies. This sheet is meant to be provided to patient surrogates, address their doubts about DNAR, and must be attached to patient records along with the signed DNAR form.

Although ICMR is primarily a research and ethics regulatory body under the Ministry of Health and Family Welfare, its pioneering initiative addressed a critical ethical and clinical gap in Indian medical practice¹. Ideally, such practice-oriented clinical guidance might have come from the National Medical Commission; nevertheless, ICMR’s effort filled a vital void amid the absence of national law or binding medical regulation. As the first authoritative document on DNAR in India, it empowered physicians to ethically and confidently make DNAR decisions without fear of legal consequences.

However, the 2020 guidelines have yet to undergo revision. While queries arising after publication were well-addressed, further updates incorporating field-based experiences, barriers, and emerging evidence are essential.^[3] Moreover, India lacks substantial literature on DNAR practice, awareness, and barriers, possibly due to the limited dissemination of the ICMR document among physicians. The guidelines recommend that hospitals raise awareness through teaching sessions, posters, training, and policy implementations to improve understanding among healthcare professionals and surrogates.^[1] This effort is crucial to avoid futile CPR, preserve patient dignity, and strengthen ethical decision-making in end-of-life care.

The release of the ICMR DNAR guidelines was a historic and progressive step for Indian medicine. A revised edition incorporating practice-based insights and addressing India-specific barriers would further enhance their practicality and clinical acceptance.

Indeed, further awareness is crucial for the effective implementation of the ICMR DNAR guidelines among physicians across India. Despite the release of these landmark guidelines in 2020, limited dissemination and awareness continue to hinder their consistent application in clinical practice.

Enhanced awareness will empower physicians to confidently engage in DNAR discussions with patients’ families, promote shared decision-making, and avoid futile resuscitative efforts. It will also facilitate uniform use of the standardized DNAR form and adherence to ethical principles embedded in the guidelines, ultimately improving end-of-life care quality.

Encouraging hospitals to implement awareness campaigns with posters, information sheets for surrogates, and regular training can create an environment where DNAR protocols are well-understood and appropriately practiced. This continuous educational approach is vital for achieving widespread dissemination of the ICMR 2020 DNAR guidelines, effectively bridging the critical gap between policy and clinical practice in Indian healthcare settings.