New State Law Covers Life-and-Death Decisions


Governor Schaefer signed Tuesday the Health Care Decisions Act, passed by the General Assembly in its just-concluded session. The new law will take effect on Oct. 1. Maryland's citizens should be aware of its content and implications.

The legislation makes Maryland citizens better able to express their desires about their medical care. The law also breaks new ground in allowing citizens to make decisions about the care of family or close friends who can no longer make decisions for themselves and who did not previously express their wishes in writing.

Ideally, we would all live a very long time and then die a dignified death with the least possible pain and suffering. Unfortunately, the reality is often very different. The longer we live, the more likely it is that the time will come when the body's organ systems (circulation, kidneys, etc.) start to fail. While modern medicine has made great advances, it remains largely unable to reverse the ravages of chronic illnesses. Also, as more creative ways have been found to save the lives of younger individuals, such as those with serious head injuries, more individuals, young and old, linger in persistent vegetative states. They have no realistic hope for recovery, and face years, or even decades, of repeated infections and other suffering before they finally die.

Every day in the United States, thousands of individuals linger in states of advanced decline, with irreversible conditions such as advanced Alzheimer's Disease, other degenerative neurological conditions such as ALS ("Lou Gehrig's Disease"), or with terminal illnesses such as cancer.

In the past several years, much progress has been made in this country in clarifying important ethical issues and the rights of people to make health care decisions without judicial intervention or state-imposed restrictions. Many studies reaffirm that most people do not want extraordinary measures that prolong life but cannot prevent significant recurrent pain and suffering. Going beyond that, many people feel that their lives would not be worth living if they would lose their ability to relate meaningfully with others or to do more than just stay alive.

In the experience of health care providers, people's opinions and values about these issues span the whole spectrum, regardless of their faith or background. Thus, no one approach or perspective should take precedence over others.

In 1990, in the case of Nancy Cruzan, the U.S. Supreme Court affirmed the constitutional right of all competent adults to refuse some or all life-sustaining medical technologies, which may include treatments such as blood transfusions, surgery, antibiotics, kidney dialysis, artificial ventilation, cardiopulmonary resuscitation (CPR) and tube feedings.

This helped reinforce the important principle that medical care is a means to an end, not an end in itself. This means that people should be able to decide that medical care should be rendered to the extent that it has value for living, not just because it exists. It left to the states the right to establish standards for deciding what to do about people who had never made formal directives but then got into a situation where such decisions had to be made.

Since then, the trend among the states has been to formalize the rights of families to make medical care decisions in conjunction with physicians and other appropriate support, without having to go to court. This new Maryland law strengthens those rights for the citizens of this state. It:

* supports the right of competent individuals to make an advance directive (a statement of wishes about health care treatment that takes effect in case of later incapacity)

* allows someone to name another person (their "agent") to make health-care decisions for them if they become incapacitated

* enables a close family member or friend to make a decision to withhold or withdraw life support for someone who did not make a formal advance directive but is terminally ill, in a coma, or in the advanced stages of a progressive, fatal disease

* allows Emergency Medical Service personnel (paramedics) to honor "Do Not Resuscitate" wishes outside of the hospital

* allows physicians to use their judgment about providing "futile" medical care

* guides judges in court cases regarding the withholding or withdrawal of life-sustaining treatment.

Effective ethical decision-making has to be a partnership between physicians and patients or those forced by circumstances to make decisions for others. The physician has critical information that laymen need to understand a medical situation. The patient has values and wishes that the physician must consider in making treatment recommendations.

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