Court Ruling Will Delay Guidelines

A recent Massachusetts Supreme Court decision has delayed the approval of guidelines regulating decisions not to resuscitate terminally ill patients at Beth Israel Hospital, the director of the hospital said yesterday.

Mitchell T. Rabkin '51, director of the Beth Israel Hospital, said the guidelines, which hospital officials had earlier predicted the Beth Israel board of trustees would approve this month, will probably not come before the board until June as a result of the delay.

"This new judicial decision only affects the portion of the guidelines concerning incompetents," Rabkin said, adding that most of the guidelines will remain unchanged.

In the guidelines, Rabkin defines "incompetents" as patients unable to make "rational" decisions.

On November 28 of last year the Massachusetts Supreme Court concluded that a lower court was correct in ruling that Joseph Saikewicz, a 67-year-old, mentally-retarded man afflicted with leukemia, could not be denied chemotherapy.

Doctors and Lawyers

Rabkin, the author of the guidelines, is now meeting with legal counsel employed by the hospital in order to revise the guidelines which he will then submit once again to the hospital's resuscitation committee for approval.

The court decision has nullified resuscitation policies based on a similar set of guidelines at Massachusetts General Hospital, the hospital's director said yesterday.

Fine

"Our guidelines worked fine, but now that's all out the window," Charles A. Sanders, director of Massachusetts General Hospital, said, adding that he thought Rabkin's proposals were no longer relevant in the light of the judicial decision.

Jim Baccarino, an attorney for the Massachusetts General Hospital, said yesterday that the Massachusetts Supreme Court has lumped withholding treatment and withdrawing treatment in the same category--in blatant defiance of the New Jersey Supreme Court decision in the Karen Quinlan case which delineated between the two.

The court ruled that life-and-death decisions determining when to resuscitate incompetent patients must be made in a court of law, Rabkin said.

Rabkin's proposals evolved from the Law and Ethics Working Group, part of a faculty seminar on the Analysis of Health and Medical Practices at the School of Public Health. Rabkin discussed his ideas with other members of the group and sought their opinions and advice.

The proposals are necessary because medical developments and technological developments in the past 25 years have greatly improved the capability to keep a terminally ill person alive, Rabkin said.

"Let me give you an example," Rabkin said. "The other day I was walking down one of the halls in the hospital, and I came across a nurse standing outside of a patient's room crying with her fists clenched."

"She looked at me and said 'Why can't they just let the poor man die.' He was a terminally ill patient with diffuse cancer. He was writhing in pain and gasping. Now should you do everything possible to resuscitate a patient in that condition?"

Previously, decisions to resuscitate were handled informally by a physician, but now recent controversies have created the necessity to "develop a methodology which allows us to make a decision that is fair, just, judicious and above board," Rabkin said.

Complexities

The problem is complex, he said, and it is difficult to decide exactly what is a moral or social question and what is a medical or clinical question.

All hospital officials contacted said that the question of responsibility for these life-and-death decisions is far from being resolved and that, in fact, the problem of accountability will continue to grow.

Rabkin's proposals allow the doctor and the patient--with the consent of an advisory committee--to agree beforehand that, after a certain point of deterioration of the patient's physical condition, the doctors will not make resuscitation attempts.

Rabkin's original guidelines also allow the family of incompetent patients to make a similar decision. This is the portion of the guidelines which the recent court decision affects