Before Dec. 1, doctors had worried that a new law requiring hospitals to discuss with patients the possibility of using artificial life support systems would unduly shock or startle some patients. Few expected David Schulte's reaction.
Mr. Schulte tried to sign a living will right in the Sinai Hospital admissions office after a clerk handed him a packet of information and explained the purpose of it.
"I'm pretty sure it's not going to be needed," said the 50-year-old Baltimore factory worker as he faced heart bypass surgery Tuesday. But, just in case, he wanted his care-givers to know how he felt about being kept alive by a machine: "I want no part of it."
The clerk told Mr. Schulte the living will had to be witnessed and was something he ought to talk over with his family and his doctor, but he was intent on getting it signed before he was wheeled into the operating room. So he enlisted the visitors of a fellow patient to witness the document.
"I think it's almost criminal to keep somebody around who doesn't have much hope of recovery," said Mr. Schulte, who was in fair condition yesterday after his operation.
Although few patients have wanted to sign a living will on the spot, many are showing an interest in documenting their wishes about the use of respirators or other such equipment, according toa dozen hospitals surveyed in the Baltimore area. "Many people are receptive because they've heard or read about it," said Paul Umansky, spokesman for Sinai.
The state attorney general's office has seen requests for living will forms and similar documents skyrocket since the new law went into effect Dec. 1. About 800 people have written or called the office for the forms, provided free of charge, compared to 50 requests in an average week, said Jack Schwartz, chief counsel for opinions and advice.
Marylanders can document their wishes about dying naturally or extending their lives with technology in three ways: The living will states the wishes of a terminally ill patient when death is imminent; the durable power of attorney for health care is broader than a living will and designates a proxy to speak for a patient in all decisions about his care if he can no longer communicate; or a patient can simply discuss his wishes with a doctor and ask the physician to note the discussion in his medical record.
Area hospitals contacted said they are notifying patients under the new law in different ways, but most leave the task to clerks handling the admission or admitting nurses who talk with the patient soon after he arrives in his room. Some use both, and many hospitals say they have trained other personnel to be ready to answer patients' questions.
At Church Hospital in East Baltimore, for example, admission clerks give new patients information about artificial life support. Then admitting nurses follow through by asking if they have signed a document and if so, noting it in the patient's chart, said patient representative Joyce Weller. Social workers, nursing management, the chaplain and patient representative are all trained to give additional information to patients who want it, she said. And patients are encouraged to discuss their wishes with their doctors.
Good Samaritan Hospital is mailing out a brochure explaining the ways patients can document their wishes along with pre-admission information. Then they are asked by both admission clerks and their admitting nurses.
But many hospital staff members say they think the most appropriate place for these discussions is not a hospital at all.
"When they get to the hospital, they're already stressed," said Nina Sinnott, spokeswoman for Good Samaritan Hospital. "It's not the best time to make a decision."
It can be downright scary to an emergency patient. At Harbor Hospital Center, patients who arrive by ambulance often get medical attention in an intensive care unit first before a nurse comes in to discuss the use of artificial life support with them and their families, said Jackie Breeden, the hospital spokeswoman.
Even in regular admissions, patients often are alarmed when the subject is broached, she said. "They think maybe there's more wrong than what their doctor told them. It puts us in a really sensitive situation."
In one instance, a man accompanying his father to the hospital got so upset upon hearing his father asked hypothetical questions about using artificial life support that "he became verbally abusive," she said. "We just need more education."
This week, Good Samaritan is mailing letters to the 500 doctors who have staff privileges there, suggesting that they talk with patients about this issue in their offices.
And soon virtually all Maryland doctors will be getting similar advice. The state medical society is mailing out letters and pamphlets to 7,000 physician members this month describing the ways patients can document their wishes about dying. The society suggests that physicians place pamphlets in their waiting rooms and talk with patients about dying when they are still well.