Advocates for better end-of-life care in Pennsylvania applaud a new law covering decision-making relating to it but say more steps are needed to protect terminally ill individuals from undesired, medically invasive treatment.

Gov. Ed Rendell last week signed legislation approved unanimously by both the House and Senate, updating state law on living wills and health care powers of attorney.

Perhaps most importantly, since the majority of people have neither of those advance directives when hospitalized, the new measure creates guidelines for treatment decisions involving such individuals.

Health care providers, elder- law attorneys and others who assist seriously ill adults say such steps are important in aiding the comfort of people receiving late-life treatment.

Advance directives and surrogate decision-making procedures help assure that ventilators, feeding tubes, CPR and other techniques are used only on those people who want it, and not for people who may wish for a more peaceful death after prolonged illness or severe brain injury.

The legislation also is intended to help avoid headline-stirring controversies over terminal cases, as occurred in Florida in 2005 with the drawn-out death of Terri Schiavo.

But more work is to be done, say officials involved in a Western Pennsylvania committee examining such issues. They are awaiting a statewide report that was expected to be released months ago on end-of-life care. They also hope the legislation will spur Pennsylvania to copy other states that encourage physicians and patients to jointly put late-life treatment preferences into writing.

"Many people don't know what their options are at end of life, so they end up with more care and service than they might have wanted," said Nancy Zionts, vice president of the Jewish Healthcare Foundation.

Participants in the legislation's development and on committees working on the topic acknowledge they have to be careful to consider religious, disabilities and minority groups that raise concerns about premature cutoff of medical services, when lives are at stake. Those interest groups had a role in crafting the new legislation and in the work of the statewide Task Force for Quality at the End of Life, which has been preparing a comprehensive report on the topic.

"Without this new law, we haven't had much to go by," said Pittsburgh elder law attorney Robert Wolf, in terms of who makes decisions for incapacitated individuals and how they make those decisions under a more vague 14-year-old statute.

"Since 1992, you could appoint a surrogate but it didn't say what the surrogate's powers were," he noted, and most didn't select a surrogate anyway.

In practice, hospitals have generally consulted on an incapacitated person's late-life treatment issues with the closest available family members or whoever else showed up claiming a relationship.

The new law spells out a pecking order of how primary decision-making will fall to spouses (so long as they're not in divorce proceedings), adult children, parents, siblings and so on. It also allows for the possibility of decisions to be made by close friends.

The law also tries to address a perceived problem with lack of use of do-not-resuscitate orders in Pennsylvania.

Patients with terminal illnesses have had the option for several years of going to physicians to have them order do-not-resuscitate necklaces and bracelets the individuals can wear, so they don't end up in emergency rooms undergoing traumatic life-preserving treatment they don't want.

Few of the necklaces and bracelets have been in use, however, as the process for arranging them has had obstacles for both patients and physicians.

Some officials are pushing instead for a more comprehensive statewide program, similar to what's used in Oregon and West Virginia, in which physicians have forms to fill out with seriously ill patients to discuss not just DNR orders but the range of life-preserving options.

Bright pink sheets called POLST orders, for "physicians orders for life-sustaining treatment," can become part of the patients' readily available records to be referred to by nursing homes, emergency medical technicians, hospitals and others regarding CPR, feeding tubes and more.

Dr. Judith Black, medical director of senior products for Highmark Blue Cross Blue Shield, said the POLST system has been adopted on a voluntary basis by some area hospitals, nursing homes and emergency medical services, but it needs to be broadened.

"It's not for use with every patient," she noted. "This is for use with seriously ill people, who it would not be surprising if they died in a year or two."

The legislation calls for the state Health Department to study creation of such a system statewide, which would require a major education process for physicians.

The state Task Force for Quality at the End of Life, a broad group spearheaded by the Department of Aging, was established in January 2005 to look at such issues as a POLST system, advance directives, hospice and palliative care, education of medical professionals on late-life care, and more.

Initial recommendations were put into writing last January, a draft report was made available to participants over the summer, and a final report could be released publicly within the next month or two, participants say.

In the meantime, a regional group, the Coalition for Quality at the End of Life, has set up committees to move forward in 2007 on public awareness, physician education and other progress that might be accomplished on such issues locally.