High technology near the end of life: setting limits.

Abstract High technology interventions near the end of life exact a high cost both in human and economic terms. Breathtaking advances in cardiology have helped to prolong life and improve its quality for many. For some, it has transformed the process of dying into a medical nightmare. The “do everything possible” attitude that prevailed during the past few decades is both inhumane and wasteful. In contrast, in the new era of managed care with its focus on profit, a well meaning physician may become suspect whenever he recommends against a medical intervention that he deems to be futile. More than ever before, there is a pressing need to develop rational guidelines for end of life medical interventions to ensure primacy of patients' best interests, protect the integrity of the doctor-patient relationship and affirm the duty of the medical establishment toward society at large. This weighty issue must not be relinquished to medical ethicists, health care ailiances or the courts. It is the domain of physicians and the public at large. Medical futility should be defined as a treatment unlikely to affect the course of illness or that which has failed to achieve its desired effects. Rational guidelines for cardiopulmonary resuscitation and do not resuscitate orders should be formulated for both in-hospital and out of hospital victims of cardiac arrest. These guidelines need to be developed through a process similar to those for the treatment of unstable angina, with involvement from all relevant medical specialities. Proposed guidelines must be negotiated, reviewed and ratified by the lay public. Appropriate legislation is necessary to establish the framework and policies to carry out agreed on recommendations. The focus of the “living will” should change so that it covers the last chapter of life rather than its terminal phase. The document should serve to express the person's wishes regarding specific medical interventions when the quality of life is seriously diminished beyond what is uniquely desirable for the particular patient. Living wills must be comprehensive, clear and specific. They must be honored. The Uniform Health Decisions Act, now pending legislation, should enhance the utility of the living will.