Living Will tells a tale

Hundreds of poor families opt for end-of-life directives; rising medical costs a key factorAncy has taken steps to ensure her children would never have to face a similar dilemma. She is now among nearly 400 people in Kerala who have prepared a ‘Living Will’
Ancy Sunny’s greatest regret in life is that she could not ease the agonising pain her mother endured in her final days. Her mother, a lung cancer patient, was barely alive despite receiving the best available treatment. Time and again, she pleaded with Ancy to let her die peacefully by stopping all treatments.

A decade ago, however, honouring such a wish would have been unthinkable. “Back then, pulling the plug would’ve been considered murder,” says Ancy, who hails from Eravipuram in Kollam district.

Not only did her mother suffer through painful chemotherapy and other procedures, Ancy was also left with a heavy financial burden.

That experience pushed Ancy to take steps to ensure her children would never have to face a similar dilemma. She is now among nearly 400 people in Kerala who have prepared a ‘Living Will’—a legal document that allows individuals to specify the kind of medical treatment they wish to receive, or forgo, should they be diagnosed with a terminal illness and become unable to make decisions themselves.


The initiative gained momentum after a 2018 Supreme Court ruling that declared the right to die with dignity a fundamental right. It laid down guidelines for the creation of Living Wills or Advance Medical Directives. Ancy completed hers at Parippally Medical College Hospital, which became the first government hospital in the state to set up a dedicated counter to help people draft these documents. Alappuzha Medical College Hospital is now preparing to follow suit.


The response has been very good so far. But unlike in Western countries—where Living Wills are more common among the educated upper middle class—Kerala’s experience shows that it is mostly the poor who are signing up, mainly because of the sheer absence of adequate medical cover. Of those who have completed the process, nearly 90% are from the unorganised sector: Daily-wage labourers, fishermen, and semi-skilled workers. A few are retired govt staff and medical professionals.

Ancy’s husband, Sijo Thankachan, is a fisherman, and the family simply cannot afford exorbitant medical bills. “I don’t want my daughters to suffer financially or emotionally like I did with my mother,” says Ancy. Her Living Will names her two daughters as surrogates to make end-of-life decisions on her behalf. The document clearly states that she does not wish to be put on a ventilator or receive CPR, chemotherapy, radiotherapy, or intravenous nutrition if she is diagnosed with an irreversible, terminal illness.

Copies of the Will are with her daughters and the Kollam Municipal Corporation, while the original is kept at home.
In Paravur, 57 members of the Thodiyil family—part of a 140-member joint family—have also prepared Living Wills. Their decision came after two family members fell into debt while caring for terminally ill relatives.

Dr IP Yadav, palliative care nodal officer at Parippally Medical College, says, “Most people who access this service come from poor or middle-class backgrounds. But we hope this will change as awareness spreads through community events.”

Of the 16 people who recently collected forms at Alappuzha Medical College, nine were BPL cardholders. The process is straightforward: Individuals collect a form from the hospital counter, sign it in the presence of two witnesses and two designated surrogates, and have it attested by a gazetted officer or notary.

Even then, withdrawing life-support treatment is not immediate. “Two separate medical boards—a primary and a secondary panel—must independently verify the patient’s condition and approve the decision to stop treatment,” says Yadav.

Alappuzha-based social activist Chandradas K has submitted a proposal to the local self-govt department to set up Living Will counters at all local bodies. He cited the controversy following the death of veteran communist leader MM Lawrence, whose family fought over funeral decisions. “That incident alone shows why legal clarity is essential,” says Chandradas.

However, concerns about misuse persist. Indian Medical Association national convener Dr Sulphi Noohu warns that loopholes in the system could be exploited. “We can’t deny someone ventilator support unless it’s medically justified. Some patients recover with timely intervention,” he cautions. “Scientific evaluation is crucial.”
Nonetheless, proponents argue that the new law empowers individuals to make personal health choices before they lose that capacity. “The essence of the Living Will is control,” said Dr B Padmakumar, principal of Parippally Medical College. “It allows people to take a decision today for a situation when they might not be able to do so.

It reduces unnecessary medical expenses, prevents family conflicts, and ensures peace of mind for everyone involved.”
Noble Gracious, executive director of the Kerala State Organ and Tissue Transplant Organization, sees another advantage: The potential to boost organ donation. “Living Wills can lead to more timely identification of donors, potentially saving hundreds of lives,” he says.

But Gracious also acknowledges the challenges. “Implementation will be the real test.” He cites a 2020 state govt order directing hospitals to certify brain death in accident cases to promote organ donation—a directive that has seen poor compliance.


“Hospitals often profit from treating terminally ill patients, leading to potential conflicts of interest. Unlike in Europe, where universal healthcare removes financial incentives, Indian hospitals can prolong treatment for revenue,” he points out.