O.C.’s Terminally Ill Can Soon Halt Medics’ Heroics

It happens at least once a month. A terminally ill patient suffers chest pains. His family knows he has signed a living will, asking that no heroic measures be taken to keep him alive. But as the end nears, a daughter panics. She dials 911.

When paramedics arrive, she watches in horror as they pound her father’s chest, trying cardiopulmonary resuscitation, then using a defibrillator to try to shock him back to life.

“No! He didn’t want this!” she shouts. But it is no time to argue. By law, paramedics are required to try to resuscitate patients, not let them die.

Again and again paramedics have brought terminally ill patients back to life--some to die in an emergency room, some to live for months in a hospital, sustained by feeding tubes and a breathing machine.

But starting Aug. 1, a new policy goes into effect in Orange County that will allow dying patients to reject emergency measures and permit paramedics to heed their wishes. Orange County is the fifth and most populous California county to adopt such a measure.

Once the patient and his doctor sign a one-page consent form, he may wear a thin green arm or leg band that will mean to all medics: “Do Not Resuscitate.” When they see the band, medics may administer oxygen and make other efforts to ease suffering but they may not use chest compression, cardiopulmonary resuscitation, defibrillation, intubation or heart-stimulating drugs to revive him. If they start CPR and then discover the band, they must stop.

This policy--years in the making--has met with approval from the Orange County Medical Assn., paramedics, the county Visiting Nurse Assn., an Orange County Bar Assn. committee and local medical ethicists.

It was long overdue, they all said. “Everyone, including the Supreme Court, agrees that patients have a right not to be treated,” said UC Irvine bioethicist Dr. Ron Miller. “This is one form of treatment that some patients find particularly offensive--to be resuscitated when they are dying--when death is not an enemy but a friend.”

Added Dr. Richard T. Pitts, a Tustin emergency physician who has spent the last six years lobbying for this measure, “This has nothing to do with mercy killing, with euthanasia.” Rather, Pitts said, the decision to wear the green band is a voluntary one, made by the patient or, if he is too ill, a surrogate. And its meaning is clear, Pitts said: “I choose to let nature take its course.” Since 1988, Santa Cruz, San Bernardino, Inyo and Mono counties have ordered their paramedics to recognize a “Do Not Resuscitate Order.” Eight states other than California allow such orders outside of a hospital. So far, no policy has faced a legal challenge.

In the wake of a 1983 report by a presidential commission that concluded patients have the right to “forgo life-sustaining treatment,” many U.S. hospitals enacted “Do Not Resuscitate” policies that allow dying patients to do so with dignity.

But outside hospitals--in nursing homes, in private homes or in ambulances--”it’s been more problematic,” said Judith Wilson Ross, a bioethicist with St. Joseph Health Care System in Orange.

When Orange County’s paramedic system began in 1973, medics were told to resuscitate patients, even when family members begged them not to and even when relatives showed them a living will.

To paramedics, the new armband system will be a great relief, they said. For at least once a month, sometimes once a week, they are caught in the middle, between the patient or his family’s wishes and state law. And the experience is upsetting, frustrating.

“We’re put in a real bad situation,” said Anaheim fire paramedic Rocky Audley.

When a cancer patient dies at home, a family member often dials 911, perhaps just seeking confirmation of the death. But once medics arrive, “The relative may say, ‘Hey, I don’t want you to work them.’ And I say, ‘Hey I’m sorry.. . . We have a legal liability to work on this patient.’ ” Audley said.

Only in limited cases--if the patient was stiff with rigor mortis or if he was decapitated, for instance--can they not resuscitate, Audley said. But “we don’t have a lot of time to sit around and explain this. We’ll basically work on them for 10 or 15 minutes at the scene, then transport them to the hospital . . . and then the family is sent a big bill from the hospital.”

Oncologists and other doctors who regularly treat terminally ill patients advise relatives to call them-- not 911--as a patient dies. They can suggest comforting measures--or simply tell families to wait it out and later call a mortuary. Death may come quietly, during sleep, they said, but sometimes it is violent, with a gasping for breath or vomiting of blood. And at times like these, even the most prepared families may panic.

“People don’t know how to deal with death--and they can’t be expected to learn with a loved one,” said Dr. Robert Bade, an emergency medical services director who knows the pain of a failed resuscitation too well.

When Bade’s frail, 96-year-old grandmother died seven years ago at her Mission Viejo home, his mother panicked and called for the paramedics. And, Bade said, “I personally experienced the anguish and unfortunate indignity of futile medical intervention.”

When Bade arrived, “they had her intubated and all the IV lines and gadgets and gizmos hooked up like she was some executive on the golf course.”

Bade told them forcefully to “cease and desist.” Because he was a doctor and an emergency medical services director, they stopped. But for Bade, the emotional damage was done. As an emergency room physician, he has seen death “a thousand times,” he said. “But I can still see the snapshot--my darling grandma, lying in the middle of the living room with her clothes ripped open and terrible things being done to her.”

Added Bade, “If it’s a sudden, unanticipated death, you should call 911. But if it is a known, irreversible medical condition that is under a physician’s care, relatives should discuss with their physician and make a conscious decision--whether or not they want every known treatment applied” when the end comes.

In 1985, a county medical committee began talking in earnest about “inappropriate” resuscitation of dying patients by paramedics. They agreed that dying patients should not be revived if they did not wish to be. The stumbling block: how are these these patients to be identified?

They agreed that paramedics should not argue with relatives at the time of a patient’s dying about resuscitation. The issue needed to be decided well before that. But, at first, “nobody thought of bracelets,” O’Rourke said.

They explored using a written DNR order, perhaps to be posted at bedside. Still, O’Rourke said, there were questions--”Is this legitimate? Is it signed by the right person? Does the paramedic stand there and read a four-page form?”

Then in 1988, emergency medical physician Pitts circulated a proposal to identify dying patients who did not wish resuscitation by asking them to wear a plastic band.

He argued that resuscitation of these patients was inhumane and costly--not just in thousands of dollars of medical care for patients who survived in a vegetative state, but also because of the potential for injury when a paramedic van goes “careening through the streets, Code 3, endangering people’s lives.”

By then, Pitts had worked on 10 terminally ill patients who had been resuscitated and rushed to his emergency room. He considered these resuscitations “wrongful.”

Over the next few years, Pitts met with paramedics, home health nurses, lawyers and the county medical association. Slowly, he made progress. Last winter, a group of hospital officials and medical ethicists called the Orange County Bioethics Network convened a daylong conference to consider if Pitts’ plan could work. A key concern--the armband. Was it a stigma, a sign of death? Was the idea revolting?

To find out, some conferees wore a lavender armband for several days after the meeting. Only one was questioned about it. When he said it meant “I will not be resuscitated,” the questioner “didn’t seem very interested,” ethicist Ross reported.

Ultimately, said Corrine Bayley, another St. Joseph ethicist, “I decided the good would outweigh the difficulty. It’s far worse to be resuscitated when you don’t want to be.”

In addition, an oncology nurse polled several dying patients about the vinyl band. All liked the idea, Pitts reported.

Still, he emphasized, the new program was voluntary. Any time the dying patient or his legal surrogate “has second thoughts,” he could cut the band and receive “the full court press.”

By this spring, a host of groups endorsed the proposal--emergency physicians, a committee from the Orange County Bar Assn. and, in May, the county’s emergency medical services division. This month paramedics around the county began receiving training about the new directive.

It will go into effect Aug. 1, though two events could delay implementation. The Orange County Medical Assn., which will keep the armbands, may not receive its first shipment of 2,000 bands until after that date. Also, a Visiting Nurses Assn. official said her agency may not start teaching home care nurses about how to offer the band until September.

Under the plan, doctors and patients will sign a consent form for the band, then a home care nurse will pick one up from medical association headquarters in Orange and attach it at the patient’s home.

Candidates for the band are not just anyone who has cancer, Pitts noted. Rather, “we’re talking about someone in the last stages of life, with no hope of recovery,” who if resuscitated, would probably live “in a vegetative state.”

Marty Aleman, a manager with the Visiting Nurses Assn., said she expected that at most “maybe a couple hundred” Orange County residents would wear the band. “It won’t impact a large number of people--but it really affects the quality of their last days.”