Pulling Plug: How the Ill Can Make a Choice

A 96-year-old man, terminally ill and comatose, was taken to Community Hospital of San Gabriel. His daughter wanted him to receive all available treatment, including life-support systems. His son wanted his father to receive no special care. And no one knew what the man wanted.

The man, whose name is being withheld and whose case history is somewhat altered to protect his privacy, was put on a life-support system and ultimately died. But hospital officials say his case illustrates a growing medical debate: minimum care versus maximum care for the terminally ill.

As a public service, the hospital sponsored a forum last week on how to reduce conflicts over the care of the terminally ill. About 300 people, most of them elderly, heard a panel of doctors, nurses, attorneys, clergy and laymen discuss the issue.

Panel members agreed that making the decision to terminate treatment of the terminally ill or prolong life with life-support systems is never easy, but that planning by potential patients will help ensure that their wishes are carried out after they are unable to speak for themselves.

Legal Documents

The strongest measures a person can take involve legal documents, which were described by Noah Rosenberg, an attorney specializing in health and hospital law.

One document, Rosenberg said, is a Directive to Physicians, generally called a living will, in which a terminally ill person can exercise the legal right to direct the doctor to withhold life-sustaining procedures. Under recent changes in state law, the physician is obligated either to follow the patient’s wishes or to transfer the patient to another doctor, Rosenberg said. He said the will is legally binding if made at least 14 days after the diagnosis and is good for five years.

The second document, called the Durable Power of Attorney for Health Care, can be executed at any time and is good for seven years, Rosenberg said. It allows a person to choose whether or not he wants life-support treatment and to designate another person to be responsible for carrying out the decision, the attorney said, but it can be revoked orally at any time. The form is available from the office of state Sen. Barry Keene (D-Sonoma), State Capitol, Room 313, Sacramento.

But, said Rosenberg, “if you don’t have either document, the family and the physician must make the decision if the patient cannot. If a decision cannot be reached, the next step is to go to the hospital’s bioethics committee, if it has one, which includes medical, legal and religious professionals.”

Patient May Change Mind

Margaret Krieger, nursing coordinator of Community Hospital’s intensive care unit, said the planning is not foolproof.

“Sometimes people are on respirators as long as four months,” she said. “Technology can extend life a long time. But sometimes the patient changes his mind during treatment and then what do you do? It is more complex to stop treatment than to start it.

“I feel the technology we use is questionable when it prolongs death. The choice is death with dignity or maintaining life no matter what the cost or stress.”

But Dr. Norman Shrifter, an internist, said that “terminating the life-support system can cause guilt and squabbling in relatives. And the doctor is helping kill the patient. That is very uncomfortable (for us).

“We try to accept the fact that we also have to recognize (the right of) patients’ asking to participate in their health care. But there have to be safeguards. We don’t want to frivolously pull the plug. There is the possible miracle phenomena.”

Extending Dying

The Rev. Richard Spencer of Arcadia Presbyterian Church questioned the wisdom of using every possible means to extend lives, saying “the enormous expansion of medical technology sometimes extends the process of dying rather than the process of living.”

The Rev. Bernard O’Connor of San Gabriel Mission said that death is not in every case an evil but that fear of death is present in contemporary culture.

Of the 300 audience members, 92 filled out questionnaires on how they felt about life and death. Ninety-nine percent said they would want to know if they had a terminal illness and most preferred to be told by a physician rather than family or friend.

On hypothetical questions involving life-support machines, more women than men wanted to pull the plug. Virtually no one had a living will or Durable Power of Attorney, but having heard of the existence of the legal documents, most said they planned to obtain copies.