The stomach cancer had already done its damage by the time the 82-year-old man was wheeled into George Washington University Hospital's intensive care unit. The mechanical ventilator, the intravenous fluids, the blood-pressure drugs and antibiotics could do nothing -- except keep the dying, comatose man alive a little longer.
To doctors and staff, it was apparent the end was near. The most humane thing, they felt, would be to let the patient die peacefully. But because he had slipped into a coma without ever discussing with his wife and daughter whether he wanted to be kept alive at all costs, the family members now found themselves paralyzed by a quandary:
To keep him alive -- or let nature take its course?
It is a scene that is becoming more and more common in Washington's 18 hospitals, where each year the lives of several hundred dying patients are extended beyond their normal span by modern technology. In George Washington's intensive care unit alone, there are about 30 such "hopeless cases" a year, each cared for until not even the life support systems can keep the patient alive, according to Dr. William Knaus, the unit's director.
The dilemmas posed by the wonders of high-technology medicine are the subject of a "death with dignity" bill on which the District of Columbia's city council is scheduled to take final action Tuesday. The bill's sponsor, councilwoman Polly Shackleton (D-Ward 3) says it will make "peaceful death" possible for the terminally ill, while doctors say it would help avoid the emotional, medical and sometimes legal limbo between life and death.
Called the Natural Death Act, it is aimed at saving families, physicians and especially dying patients from an undesired struggle to prolong life. Patients 18 years or older could sign an affidavit declaring that they would prefer to be allowed to die rather than be treated and remain terminally ill or comatose.
Affidavits would be binding on physicians, who would face $5,000 fines and suspension or revocation of licenses for refusing to honor such a wish.
Ten states already have enacted similar laws. Neither Maryland nor Virginia has done so.
While support for the proposed bill is strong within the medical community, legal and medical experts who have studied it say it will not be a cure-all for the thorny questions of life versus death in a modern medical setting.
It would have done nothing, for instance, in the celebrated Karen Ann Quinlan case in New Jersey, because she was less than 18 when she was stricken, and such young patients with unexpected trauma would never have had the chance to sign forms. And, in a nation where roughly 75 percent of people do not execute legal wills, it is questionable whether many will bother to exercise such "living wills" to anticipate their deaths, the experts say.
Beyond that, the bill also may be fuzzy because it leaves crucial terms undefined, according to Dr. Joanne Lynn, an assistant clinical professor at George Washington's division of geriatric medicine.
The bill requires two doctors to certify the illness is terminal and two disinterested witnesses to certify the patient's signature, and it allows for a patient's cancellation of the affidavit. Lynn said she foresees troubles arising in determining whether the illness is indeed terminal, whether forms were properly witnessed and whether patients were really mentally competent when signing.
However, Dr. Lewis H. Biben, president of the D.C. Medical Society, said he discussed these concerns with Lynn and believes the "fuzziness" of the bill is not only acceptable but preferable, because it will assure that doctors and families are extremely careful.
At the same time, the bill has drawn fire from some area church leaders, including the Most Rev. James A. Hickey, Roman Catholic archbishop of Washington, who told Shackleton in a letter that it "could contribute to a declining respect for human life, especially the life of the feeble, sick, and handicapped." The bill is opposed on similar grounds by the Rev. Andrew Fowler, executive secretary of the Committee of 100 Ministers.
Knaus believes that the bill would have been helpful in the case of the 82-year-old cancer patient who spent his last month on life support in the intensive care unit, where individual treatment costs can range from $900 to $1,500 a day, depending on the technology employed. If the man had signed such an affidavit indicating a desire to avoid "heroic" treatment measures, Knaus said, "then it would have made it all so much easier" for the doctors and nurses and especially for the family.
"The family has to live with this forever," he said. "It is very important to recognize when you are doing more harm than good. . . . You have to ask whether you are adding to the emotional and financial cost."
After several weeks of futile medical effort against the stomach cancer, Knaus said, it became clear that medical intervention was useless because of massive failure of crucial organs. Doctors believed the man should be declared a "blue star" case -- which is hospital jargon for what is formally called a "no-resuscitation order."
In such hopeless cases and after agreement from either patient or family, most hospitals have a procedure in which the patient's chart is marked to indicate that no effort is to be made to revive a terminally ill patient. About 30 ICU cases at GWU are blue-starred every year, Knaus said.
But in the old man's case, as in many others, the family had never discussed death, Knaus said, and found themselves paralyzed by the question of whether their now-comatose loved one would want to suffer further, or be blue-starred and be done.
The bill would be "extremely valuable," not just for the emotions of families, but for doctors too, said Dr. Harold Hirsh, a physician and lawyer who teaches legal medicine at American University, George Washington and other colleges. He said it would relieve a tremendous burden from doctors forced to make life-and-death decisions, and would also allay some of their fears about malpractice suits by making the cases more clear.