Right-to-Die Powers Asked in San Diego : Bar, Medical Society Rules Allow Patient, Family to End Suffering

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, “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.”

The guidelines are the result of a two-year study requested by Superior Court Judge Milton Milkes, who 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. Milkes ordered that the tube could be removed, but that the doctor who had objected did not have to do it.

The woman, Anna Hirth, eventually 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.”

“No venue has ever come up with such detailed guidelines as we’ve done in San Diego County,” Milkes said. “I think we’re at the forefront to prevent tragedies.” 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 where a father held hospital staff at bay with a gun while he disconnected his son’s life-support system might have been avoided.

“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 withdraw life-prolonging treatment should be “based on the physician’s professional judgment and the wishes and best interest of the patient.”

The guidelines also state that 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.

Minors 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. 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.

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.