In a significant step to strengthen patients’ autonomy in end-of-life medical care, Tamil Nadu has issued guidelines for Advance Medical Directives (AMD), allowing adults to formally record their wishes on withholding or withdrawing medical treatment at a time when they become incapable of communicating or making healthcare decisions.The State government has issued the “Tamil Nadu Advance Medical Directive Guidelines, 2026” for the implementation of AMDs in the State. Tamil Nadu referred to a Supreme Court (SC) judgment laying down the principles relating to the procedure for the execution of AMDs, and provided guidelines to give effect to passive euthanasia where there are AMDs and where there are none.Shireen Yachu, Senior Resident Fellow, Vidhi Centre for Legal Policy, said the court in Harish Rana vs Union of India asked States to file responses on the status of implementation of the Common Cause orders (which included setting up of medical boards, appointing custodians for the storage and safe keeping of AMDs) and States responded with orders of the mechanisms.She said it was a significant order as 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 T.N. guidelines, every adult will have 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, if the person becomes incapable of decision-making.A copy must be given to the guardian/close relative, 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 any time he/she has the capacity.If the executor becomes terminally ill and is undergoing prolonged medical treatment with no hope of recovery, and does not have the decision-making capacity, the treating physician, when made aware about the AMD, should ascertain the genuineness.Under the guidelines, every treating institution must maintain a panel of experts to form a Primary Medical Board when required. It should consist of the treating physician and two experts from the institution with at least five years’ experience. The JDHS must also maintain a panel of registered medical practitioners from which the treating institution can choose to constitute a Secondary Medical Board. The two boards must determine whether the AMD’s instructions to withdraw or refuse further treatment must be followed.The hospital where the patient is admitted should convey the decision of the two boards and the consent of those named in the AMD to the jurisdictional Judicial Magistrate First Class. If permission to withdraw medical treatment is refused by the Secondary Medical Board, the persons named in the AMD or the treating physician or the treating institution can approach the High Court. The guidelines have also outlined procedures when there is no AMD.Noting that the executor may incorporate the AMD into digital health records, Ms. Yachu said, “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.” 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.Ms. Yachu said 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 AMD. They should know how to deal with end-of-life care, palliative care and shared decision making,” she noted. Published - August 12, 2026 12:16 am IST