Right to Die Moves Beyond Hospitals : Some states to provide ID that tells emergency crews not to attempt life-saving measures.

The right of terminally ill patients to refuse emergency life-saving treatment in a non-hospital setting is being affirmed this summer in state laws and regulations from California to New York. Montana, which passed the first such law in April, will begin in September issuing bracelets ordering ambulance crews not to resuscitate anybody wearing one.

New York enacted a similar law on July 4 and hopes to issue bracelets by the fall. Connecticut and some California counties are instituting bracelet-based do-not-resuscitate programs, but through administrative regulations rather than legislation. New Jersey Gov. James J. Florio signed on July 11 a bill that allows “living wills” to be honored by ambulance crews, but the administrative details have not been worked out. However implemented, said Fenella Rouse, executive director of the New York-based Society for the Right to Die, programs that allow people to die as they wish are “excellent and very progressive.”

BACKGROUND: Common law and the fear of lawsuits compel ambulance crews to revive anybody whose heart stops, Rouse said. But many terminally or chronically ill patients do not want to be revived when death approaches if it means continuing a hopeless and often painful struggle for life. Bracelets that unambiguously indicate a person’s desire not to be resuscitated will protect both the patient and the ambulance crew, she said.

“Emergency personnel are trained to save lives,” she said. “First, we tell them to do everything to stop a death; now, we’re telling them not to in some cases. Fair enough, but they want to know when to do what.”

Terminally ill patients have long been able to ask their doctors to sign a do-not-resuscitate order.

And people have also been able to prepare a “living will,” a document often signed by healthy individuals that specifies how they would like to be treated if an illness or injury should render them unable to communicate with their doctors.

But “living wills” and do-not-resuscitate orders generally are effective only in hospitals. Dr. Ira Byock, a Missoula emergency room and hospice physician who is the principal author of the Montana bill, recounted numerous instances in which ambulance crews beat on the chests of terminally or chronically ill patients--people who had clearly indicated a preference not to have such procedures performed--as family members shouted at them to stop.

“Until now, emergency personnel had no choice but to follow their standard procedures,” he said. However, when ambulance crew members see the bracelet, he said, they will be able to honor the patient’s wishes and be immune from criminal or civil penalties.

“For (emergency medical technicians), it has to be black or white,” Byock said. “You can’t have ethical shades of gray in an emergency situation.”

THE TREND: Montana, whose program will be called Comfort One, plans to issue steel bracelets similar to the Medic-Alert bracelets worn by patients with conditions such as allergies to medication.

California’s Emergency Medical Services Authority issued guidelines last year for counties wanting such a program. “We didn’t feel we needed to go to the Legislature because in California we recognize (that) a patient already has the authority” to reject treatment, said Dan Smiley, the agency’s director. San Bernardino, Santa Cruz, Inyo, Mono and Orange counties have since instituted out-of-hospital do-not-resuscitate programs using bracelets and signed documents, Smiley said.

Although all the new state and county programs require a physician’s signature for a do-not-resuscitate order, they contain significant differences. Connecticut, for example, allows such orders only if the person has six months or less to live, but California, Montana and New York specifically include patients with chronic, but not necessarily terminal, conditions such as stroke or end-stage diabetes.

Connecticut has made the bracelet mandatory, but the others allow for a signed form or wallet card to identify such patients. “Under our system, all a patient has to do to revoke the order is cut off the bracelet,” said E. Marie Wilson, chief of field services for Connecticut’s Emergency Medical Services.

The others decided not to make the bracelet mandatory in case patients find it stigmatizing or uncomfortable. “Why should people have to wear a piece of jewelry they may not like in order to enjoy their rights?” Byock asked.