Decisions about Life and Death

October 08, 1993

"Living wills," documents expressing in advance a person's wishes about life-prolonging treatments, were first authorized in California in the mid-1970s and later spread across the country. But now, almost two decades later, only about 20 percent of Americans have written a living will or appointed a health care agent to make those decisions for them.

Clearly, this society urgently needs other ways of making life-and-death choices for people unable to make those decisions themselves. The Health Care Decision Act, which took effect last Friday, puts Maryland in the forefront of states that have given serious thought and attention to the tangle of ethical and legal issues surrounding the ways increasing numbers of Americans die.

The new law is the product of a lengthy and wide-ranging discussion among representatives of the medical, legal and religious communities, hospitals, nursing homes and legislators. It is not perfect, but it goes much further than most other states in addressing the hard issues in the right-to-die debate.

The new law updates Maryland's laws governing "advance directives," such as living wills or health care proxies or decision-making agents and adds the important provision that these directives should be honored by emergency paramedics as well as by hospitals and other institutions. (Until now, even Marylanders who have recorded strong objections to life-prolonging measures could find themselves hooked to machines since Emergency Medical Service personnel rarely honored advance directives.)

It extends coverage not just to those who are in the final stages of a terminally illness or who are deemed to be in a persistent vegetative state, but also to patients who are in the advanced stages of a progressive and fatal disease like Alzheimer's.

One of the law's most important contributions is to offer a framework for making these decisions in the absence of an advance directive. In brief, the law allows a family member or friend who can demonstrate a close tie to the patient to make decisions about withholding or withdrawing life support. In cases where no agreement is reached, families always have the option of going to court to reverse a decision.

Questions about life and death are made even tougher by the absence of clear legal guidelines. The new Maryland law gives families an important role in decision-making, allows physicians to use their judgment about providing medical care they regard as futile and offers guidelines for judges faced with disputes about the withholding or withdrawal of life-sustaining treatment. That's a big step forward.

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