America's love-hate, hope-fear relationship with life-saving medical technology such as respirators and feeding tubes has taken yet another twist in a new report to Congress.

"Ironically," states the report by the congressional Office of Technology Assessment, "while hospitals were once feared as 'places to die' because so little could be done to avert death, some people now fear hospitals as places to die because so much can be done."

The 459-page report details the exquisitely complex problems involving decisions about use of high-tech medicine. One of the main conclusions of the panel of experts advising OTA was that such decisions "must be made on an individual basis and should never be based on chronological age alone."

The panel also found that "there is little need or room for federal legislation concerning the initiation, withholding or withdrawal of specific life-sustaining technologies."

The report focuses on five life-sustaining medical technologies or treatments that are used on patients of all ages but affect elderly patients disproportionately. The five are: resuscitation to restore heart beat, circulation and breathing after cardiac or respiratory arrest; mechanical ventilation to boost or restore breathing; kidney dialysis to filter wastes out of the blood when the kidneys have failed; nutritional support and hydration by tube to the digestive tract or directly into the bloodstream, and antibiotics to fight life-threatening infection.

Of the five, only antibiotics can cure the underlying condition that requires their use. Patients often become permanently dependent on the other treatments, and some patients require more than one, along with other care.

For many patients, such treatments offer a lifeline. But for patients with no hope of recovery and for their families, the use of such therapies can raise agonizing medical, ethical and financial dilemmas.

"With tubes, needles and a little mechanical wizardry, we can work medical miracles today, sustaining life where previously no choice existed," said Sen. John Heinz (R-Pa.), ranking Republican of the Senate Special Committee on Aging. "But like other miracles, these procedures evoke heated emotional debates, with the conflict often carried from the hospital room to the court room."

The report includes numerous broad findings and legislative options but makes no specific recommendations, leaving policy up to Congress. The Office of Technology Assessment (OTA) was created in 1972 as an analytical arm of Congress to help legislators anticipate technological changes and their impact on people's lives.

The OTA report grew out of a request in 1984 by Heinz, who was then chairman of the Senate Special Committee on Aging, and Rep. Edward R. Roybal (D-Calif.), chairman of the House Select Committee on Aging. They asked OTA to study the ethical, social and financial implications of life-sustaining medical technologies.

Much of the impetus behind the report came from the congressional committees' fear that cost concerns and fiscal incentives might be prompting hospitals to deny older patients the same access they grant younger patients to life-saving treatments.

In researching and writing the report, OTA staff were advised by a 20-member expert board chaired by Dr. John W. Rowe, chief of gerontology at Beth Israel Hospital in Boston.

The growing number of older Americans and mounting concern about the cost of health care, Rowe said, have led to "tremendous tension" and an array of conflicting views about what is appropriate care for "terminally ill, frail, often demented very old people."

Age itself contributes less to the prediction of how a patient will fare on a respirator or other life-sustaining medical technology than other factors, such as severity of illness, diagnosis and previous health history, the report concluded.

"The older people become, the less like each other they become," Rowe said, adding that he tells medical students: "If you've seen one old patient, you've seen one old patient."

Neither age nor diagnosis alone is a reliable basis for judging a person's health or quality of life, Rowe said. For example, to say a man is 87 years old is to say little or nothing of his health or wellbeing.

To illustrate the inadequacy of diagnosis alone as a criterion for judging health, Rowe described a man who is a 75-year-old diabetic with heart disease and a previous history of cancer.

"You can't tell me," Rowe said, "whether that man is in a nursing home or sitting on the Supreme Court."

A patient's age is not irrelevant but should be considered by a doctor only in the context of other measures of health, Rowe said. "We're not age-blind," he said. "But age cannot be a central tenet. That is a slippery path."

In 1983, Medicare revolutionized its system of reimbursing hospitals for care of patients 65 and older. The new system, called prospective payment, pays hospitals the same amount for care of all patients with the same diagnosis, regardless of how long they stay in the hospital. Payment is by diagnosis, one fee for each of 471 diagnosis-related groups, or DRGs.

Critics charge that DRGs give hospitals an incentive to discharge elderly patients "sicker and quicker," sometimes without adequate arrangements for follow-up care.

The OTA report noted such fears but concluded: "Despite financial incentives to limit expensive care, there is no evidence to date that {prospective payment} has reduced access to life-sustaining treatment."

"It's very hard to find anything but anecdotal evidence about denial of care on the basis of age," said OTA project co-director Katie Maslow.

Though no one wants to base a life-or-death medical decision on financial considerations alone, cost is an undeniable concern. And lack of available resources can force a kind of rationing of care in some instances.

"If there are three beds in an intensive care unit and four patients, or 10 donor kidneys and 20 patients awaiting transplantation, difficult decisions must be made," the report acknowledges. "At every level, our current fiscal consciousness intensifies the need to make wise choices -- and to be able to demonstrate the benefits." Most hospitals and nursing homes do not have written policies for decisionmaking on use and withdrawal of life-sustaining treatment, Maslow said, and those that do focus almost exclusively on guidelines for resuscitation, ignoring other technologies such as intravenous feeding, artificial respirators and kidney dialysis.

Among other findings, the report said patients are often left out of the decision to use a life-sustaining treatment, either because they are unconscious or mentally incompetent at the time or because of confusion about who is responsible for such decisions. It calls on individuals to prepare for such decisions by making their views known in advance through "living wills." The District and 38 states have established standards for living wills.

Heinz said legislation regarding living wills and durable power of attorney for health care should be left to the states, not the federal government. But a major finding of the report, he said, is "the need for clear guidelines to ensure that health care institutions apply life-sustaining technology in the most humane, fair and effective way possible."

Heinz said he has not decided yet whether Congress should require hospitals and nursing homes to establish such guidelines to follow when deciding whether to put a patient on -- or take a patient off -- a life-support system such as a respirator or feeding tube.

Asked why he was hesitant, Heinz said he was waiting for the results of an OTA conference this October, at which hospital officials and other health providers will have a chance to express their views.

Without that information, he said, "We might get bad process because we were simply requiring a process."