People who want to forgo the lifesaving efforts of rescue crews now bring the law to their side. They can make their wishes forever known by wearing an official bracelet or posting a form that reads: "STOP DO NOT RESUSCITATE."
On July 1, Maryland quietly ushered in a law that extends the right to die without mechanical intervention to the frenzied arena of emergency medicine. Now, ambulance crews accustomed to saving lives must consider first whether patients would rather die peacefully.
The law is being embraced by chronically ill people who fear they will be brought back to a life of severe disability. It also is being welcomed by rescue personnel who say it brings sanity to cases in which they might feel obliged to resuscitate people without knowing their wishes.
"This is a breath of fresh air," said Dr. Robert R. Bass, executive director of the Maryland Institute for Emergency Medical Services Systems.
"It takes the pain out of a lot of potentially terrible situations and smooths them out. Anybody who has spent any time in the field where this stuff happens knows that EMS has had to deal with this problem for decades," said Dr. Bass, whose organization oversees rescue squads and other emergency care providers.
The law is part of a more sweeping act passed by the state legislature in 1993. Initially, the Health Care Decision Act set up procedures by which patients could prevent hospitals from resuscitating them or using life-support equipment.
Until the new provision was phased in this month, people lacked a legal mechanism to prevent rescue personnel from using electric paddles, breathing tubes or cardiopulmonary resuscitation in the field.
"They could literally be brought back before they ever got to the hospital, which would be frustrating their desires," said Sarah Sette, an assistant attorney general assigned to the state's emergency medical services.
In all likelihood, the do-not-resuscitate option will be chosen mainly by people in the end stages of cancer, heart disease, AIDS and other terminal illnesses, Dr. Bass said. But it may also appeal to healthy individuals who are philosophically determined to die without mechanical intervention.
Maryland joins Virginia, West Virginia, Washington state, Tennessee, California, Maine and New Mexico in adopting a law aimed at emergencies.
Virginia has mailed more than 50,000 forms to hospices, doctors, nursing homes and individuals since its program began in 1992. It is not known how many people filled out the forms.
Susan McHenry, Virginia's EMS director, said the law has greatly relieved the pressure on emergency squads. Before it went into effect, she said, rescue teams often felt compelled to override the wishes of family members who argued against lifesaving measures.
Without a document certifying the patient's wishes, emergency personnel feared they could be sued if they failed to make every effort to save someone's life.
"They couldn't just take the word of a family member," Ms. McHenry said.
Dr. Alvin Moss, who oversees West Virginia's program, said the law has had an additional effect. Because many people are choosing to forgo CPR ahead of time, some families do not summon rescue squads when the end comes.
Instead, they consult a family physician or hospice nurse -- and allow the person to die.
More than 15,000 requests have been made for do-not-resuscitate cards since West Virginia's law went into effect a year ago, Dr. Moss said.
In Maryland, people who want to put do-not-resuscitate orders into effect must:
* Contact the state's EMS office in Baltimore -- at (410) 706-4367 -- and request a form. The form must be co-signed by a physician. If the applicant is not competent, it may be signed by a legal guardian or a close relative acting as a surrogate.
* Cut out a strip designated on the form and insert it into a plastic sleeve. Together, they constitute a bracelet that can be worn at all times.
* Post the form in the bedroom or some other place that is easily seen.
Because the provision is so new, it is doubtful that many people are wearing the bracelets or posting forms. But Ms. Sette said nursing homes and hospitals have reacted enthusiastically.
"They are ordering them by the hundreds," she said.
Few individuals have done so, perhaps because the law has not been publicized widely.
Albert Rosen, a retired psychologist who lives in a complex for the elderly in Prince George's County, learned of the law a few weeks before it went into effect. As Washington-area president of the Hemlock Society, a group that promotes right-to-die measures, Mr. Rosen keeps tabs on such things.
He said he discussed the provision with his cardiologist. Before long, he will have his bracelet.
Mr. Rosen, 76, survived cardiac bypass surgery 15 years ago and now battles lymph cancer with chemotherapy. Although his cancer is receding and his heart doesn't trouble him, he wants to die peacefully when his time is up.
He said he has seen the alternative, and it does not please him.
"We have so many people in our nursing home who would have been protected from extreme dementia," he said. "They are just wandering around with advanced dementia because there wasn't a law to protect them."
He said he is concerned that someone might try to resuscitate him several minutes after he has stopped breathing -- too late to prevent significant brain damage.
"I wouldn't want to be resuscitated and be a vegetable," he said.
The introduction of CPR in the 1960s gave rescue workers the ability to revive people dying from reversible conditions such as irregular heartbeats and mild heart attacks. But as successes mounted, the expectation grew that squads could achieve similar results with patients dying from ravaging illnesses.
"We may initiate resuscitation efforts, inflict suffering, upset the family and in fact it's not going to do any good," said Dr. Bass. "The patient is going to die anyway. We should recognize [death] as a normal part of somebody's life process and try to work with that as best as possible."
Said Dr. Moss: "We got into a position of doing a procedure that we know has less than a 5 percent or a 10 percent chance of working."
And the procedure isn't painless. A third of patients receiving CPR suffer fractured ribs or breastbones, Dr. Moss said. "Many end up in a persistent vegetative state. Some are successfully resuscitated but with significant brain damage."
To be fair, emergency workers are not automatons. "There are some situations where perhaps we have inappropriately tried to resuscitate," Dr. Bass said. But rescue crews have also withheld resuscitation "in a low-profile way" when the futility of extreme measures is obvious.
Throughout Maryland, rescue companies are being trained to look for the bracelets and forms.
"The general consensus of the providers is that it's about time," said Bill Hardy, the prehospital care coordinator for Allegany and Garrett counties.