‘Do Not Resuscitate’ Plan for Dying Begins : Health: Orange County program will issue arm or leg bands to terminally ill who want them. Bands tell paramedics not to attempt heroic measures.

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 and dials 911.

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

Although she knows he wanted no such measure taken, it is no time to argue. By law, paramedics are required to try to resuscitate patients.

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

But this month marks the start of a new policy in Orange County that allows dying patients to reject emergency measures and permits paramedics to heed their wishes. Orange County is the fifth and most populous California county to adopt such a measure.

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

“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. 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 paramedics to respect a “Do Not Resuscitate Order.” Eight states other than California allow such orders outside 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 policies permitting “Do Not Resuscitate” orders.

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

Paramedics say the arm band system is a great relief. Often they are caught between a patient or his family’s wishes and state law.

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

In 1985, a county committee began talking in earnest about “inappropriate” resuscitation of dying patients by paramedics. While members agreed that such patients should not be revived if they did not wish to, the stumbling block was how to identify them.

In 1988, Pitts circulated a proposal to identify dying patients who did not wish resuscitation by asking them to wear a plastic band.

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

Over the next few years, Pitts met with paramedics, home health nurses, lawyers and the county medical association. Last winter, a group of hospital officials and medical ethicists known as the Orange County Bioethics Network convened a daylong conference to consider Pitts’ plan.

By spring, a host of groups had endorsed the proposal--emergency physicians, a committee from the Orange County Bar Assn. and, in May, the county’s Emergency Medical Services. This month paramedics around the county began receiving training on the new directive.

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

Candidates for the band are patients in “the last stages of life, with no hope of recovery,” who if resuscitated probably would live “in a vegetative state,” Pitts said.

Although Marty Aleman, a manager with the Visiting Nurses Assn., said she did not expect the change to involve more than a few hundred residents, “it really affects the quality of their last days.”