WASHINGTON -- Life-and-death decisions involving thousands of critically ill people could be profoundly affected next year under a new law requiring that patients be informed of their right to refuse life-prolonging care.
Starting next year, all adult patients must be told on admission to a hospital, nursing home or health maintenance organization how to prepare a legally binding living will, which typically directs doctors not to use heroic measures in hopeless cases.
As a result, death could come more swiftly for thousands of critically ill people in years to come, according to medical researchers. Although sponsors of the law deny they were motivated by the prospect of savings, it might also trim billions from the federal health care bill.
If living wills were universally available and conscientiously applied, "We could reduce [life-prolonging treatments] in older patients maybe 30 to 40 percent," said Dr. Donald Murphy, a geriatric specialist and assistant professor of health care sciences at George Washington University Medical Center here.
The law is expected to make living wills universally available and a routine part of medical practice. It requires that patients be given an explanation of living wills and the laws governing them in their state. They also will be asked if they have a living will, and their answer will be made a part of their medical records.
Because state laws vary widely, Congress has given the medical community until Dec. 1, 1991, to prepare for the requirements. Failure to inform patients after that could result in a medical institution's being barred from Medicare and Medicaid.
"These are very important developments because it means that living wills will become much more of a mainstream matter," said Doron Weber, spokesman for the Society for the Right to Die, a non-profit patient rights' group in New York.
The society has received 500,000 requests for living-will forms since June, when the U.S. Supreme Court ruled that Nancy Beth Cruzan, a Missouri woman comatose since a 1983 auto accident, may not be disconnected from a feeding tube and allowed to die because she had not left clear and convincing evidence of her wishes.
Sponsors of the measure, which is supported by the American Hospital Association, say the Cruzan case spurred congressional approval.
"Hospitals don't want to be caught in the middle between patients' wishes and family wishes. This would clarify a very delicate issue," said William Erwin, a spokesman for the American Hospital Association in Chicago.
Critics of the new directive say that it asks patients to take up a profound question without warning and that it could result in their signing away rights to care without adequately considering the consequences.
"People are encouraged to sign a document about what they might or might not want . . . in an unknown situation," said Mary Senander, public information director for the Inter
national Anti-Euthanasia Task Force of Steubenville, Ohio. "This is one more document put in front of you [at admission] without the terms explained to you."
Ms. Senander said a living will "grants immunity for discontinuing ordinary, necessary and readily available treatment and care."
However, the new law does not require anyone to sign a living will, said Cynthia Mann, spokeswoman for Representative Sander M. Levin, D-Mich., a sponsor. It "doesn't recommend a course of action, doesn't recommend pulling the plug."
In fact, a living will could request doctors to spare no effort to keep someone alive, extending life as well as adding to the cost of care, according to a Levin aide. Because people can call for more care and not less, the sponsors say they don't project any Medicare savings as a result of the living-will provisions.
But former Congressional Budget Office Director Alice Rivlin, an expert on aging issues and health care costs, said this reasoning sounds "a little disingenuous" because few people actually request heroic measures in their living wills.
"I think [the living-will provision] is a good idea, and it might save some money," said Ms. Rivlin, now an economist at the Brookings Institution.
In testimony on the high cost of treating the terminally ill in 1987, Dr. Otis Bowen, then health and human services secretary, told the Senate Finance Committee that Medicare spent $7 billion annually caring for patients in the last 40 days of their lives.