Doctors, Bar Develop Right-to-Die Guidelines

In what they described as the nation’s most detailed right-to-die guidelines, the San Diego County Bar Assn. and the county’s Medical Society on Thursday advocated the right of terminally ill patients or their families to end life-prolonging measures, including intravenous feeding.

Under the guidelines, when a patient or his family requests that he be allowed to die, “the doctor does not have to provide any artificial means of prolonging life,” said Dr. Lynn Sheffey, president of the San Diego County Medical Society. “There is no obligation to provide unusual treatment other than basic hygienic-type treatment. There is no need to maintain artificial feeding. There is no need to maintain the respirator.”

Superior Court Judge Milton Milkes, who requested that guidelines be developed, said, “No venue has ever come up with such detailed guidelines as we’ve done in San Diego County. I think we’re at the forefront to prevent tragedies.”

The guidelines are the result of a two-year study requested by Milkes after he handled a particularly troubling case 2 1/2 years ago. In 1986, Milkes was asked by the daughter of a 92-year old woman to order the removal of her mother’s feeding tube after her doctor and nursing home staff refused to do so. Milkes ordered that the tube could be removed, but that the doctor who had objected did not have to do it.

Transferred to Another Home

After a months-long standoff between the doctor and the courts, the woman, Anna Hirth, was transferred to another nursing home, where she died a week later, on May 21, 1987. She had been in a vegetative state since a choking incident in February, 1986.

At a press conference in Milkes’ courtroom, Sheffey said the committee “agonized over virtually every word,” but in the end reached unanimous agreement on the guidelines. Doctors may end treatment if “the decision has been made by the patient, by the family or someone taking the place of the patient” under the guidelines.

Milkes said he endorsed the guidelines and added, “Certainly, in this county, the physician is acting reasonably when he follows the guidelines.”

If such guidelines had been in place in Chicago, he said, the recent case in which a father held hospital staff members at bay with a gun while he disconnected his son’s life-support system might have been avoided, he said.

“Apparently Cook County (Ill.) did not know how to proceed,” Milkes said. “I think we do now.”

The guidelines, which are not legally binding, say the decision whether to withhold or withdraw life-prolonging treatment should be “based on the physician’s professional judgment and the wishes and best interest of the patient.” They are intended to “assist doctors in deciding on cardiopulmonary resuscitation, use of respirators, and intravenous feeding and hydrating.”

Doctors are not “ethically obligated to offer, employ or maintain a treatment that is futile,” the document says. But, because there is no accepted standard of “futility,” the doctor should consult other physicians and they should reach a consensus.

Also, a doctor is not obligated to do something he finds “ethically objectionable,” such as withdrawing life support, as in the Hirth case. However, if a disagreement arises between a doctor and the patient or the patient’s family, the doctor is obligated to transfer the patient to the care of a doctor who will accede to the family’s wishes.

“Competent patients,” those who understand the nature of their illness and the consequences of medical decision, have the right to forgo life-sustaining treatment, the document says.

Minors, generally those under the age of 18, would be allowed to forgo medical treatment only with the consent of a parent or guardian. Patients who are comatose, unable to understand their situations, or unable to communicate, have the same rights as competent patients, the guidelines say. But their treatment may be terminated only if they have drawn up a directive to their physicians before becoming incompetent. If no directions have been drawn up, the decision to end treatment can be made by a relative or court-appointed conservator or surrogate.

Patient’s Wishes Important

In deciding to end treatment, the surrogate must consider the wishes of the patient, if they are known.

In deciding whether a treatment is beneficial, the surrogate may not consider “whether the patient is of benefit to society,” the patient’s status, age, or other non-medical matters. Further, the surrogate “may not consider whether the patient is a burden to others.”

The decision should be based on the length of time the treatment is likely to extend life, whether the treatment is likely to result in an improvement of the patient’s condition, and the degree of discomfort or pain which may result from, or be alleviated by, the treatment.

Sheffey said such decisions are now made informally by doctors and patients on a case-by-case basis, sometimes ending with court action.

The guidelines will be disseminated in the legal and medical communities and to all hospitals in the San Diego area.

In 1985, the Los Angeles County Medical Assn. and the county Bar Assn. developed guidelines that endorsed similar patients’ and doctors’ rights, but were less specific about procedures that should be followed by doctors, patients and their families.

The San Diego guidelines, for instance, spell out in detail how a surrogate should be chosen to represent an incompetent patient. In the case of an adult, the document says, the first choice for surrogate would be the person designated in a document called the “Durable Power of Attorney for Health Care.” If there is none, the surrogate would be a conservator appointed by the court. If neither exists, a relative or close friend could act on behalf of the patient.

The document notes that there is an “emerging consensus” that a close friend may be “parallel or superior to a family member as a surrogate.” In attempting to determine whether a family member or friend is the appropriate surrogate, the doctor should find out who is in the best position to know the patient’s feelings and desires in regard to treatment, who is most concerned with the patient’s comfort and welfare, and who shows an interest in the patient by visiting or inquiring about his condition.

Following the incident in Chicago April 26, a committee of Cook County lawyers and doctors was established to draw up guidelines aimed at preventing such situations.

In that case, Rudolfo Linares disconnected his comatose 15-month-old son from a respirator and cradled the dying baby while holding the hospital staff at bay with a gun. The child had suffered irreversible brain damage nine months earlier after accidentally inhaling a balloon, but hospital officials refused Linares’ requests that the child’s respirator be disconnected.