HIGH-TECHNOLOGY NEAR THE END OF LIFE - SETTING LIMITS

High technology interventions near the end of life exact a high cost b oth in human and economic terms, Breathtaking advances in cardiology h ave 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 fe w decades is both inhumane and wasteful, In contrast, in the new era o f managed care with its focus on profit, a well meaning physician may become suspect whenever he recommends against a medical intervention t hat he deems to be futile, More than ever before, there is a pressing need to develop rational guidelines for end of life medical interventi ons to ensure primacy of patients' best interests, protect the integri ty of the doctor-patient relationship and affirm the duty of the medic al establishment toward society at large, This weighty issue must not be relinquished to medical ethicists, health care alliances or the cou rts, It is the domain of physicians and the public at large, Medical f utility should be defined as a treatment unlikely to affect the course of illness or that which has failed to achieve its desired effects, R ational guidelines for cardiopulmonary resuscitation and do not resusc itate orders should be formulated for both in-hospital and out of hosp ital victims of cardiac arrest, These guidelines meed to be developed through a process similar to those for the treatment of unstable angin a, with involvement from all relevant medical specialities, Proposed g uidelines must be negotiated, reviewed and ratified by the lay public, Appropriate legislation is necessary to establish the framework and p olicies to carry out agreed on recommendations. The focus of the ''liv ing will'' should change so that it covers the last chapter of life ra ther than its terminal phase, The document should serve to express the person's wishes regarding specific medical interventions when the qua lity 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 wil l.