In matters of discontinuation of life-sustaining treatment, traditional role of the family to speak on behalf of the incompetent patient is questionable. We explore the reasons why physicians perceive patient autonomy to be transferrable to family members. Principle of patient autonomy may not suffice when futile treatment is demanded and may serve to erode the ethical integrity of medical profession. An enhanced role for bioethics committees is proposed when physicians propose to discontinue life-sustaining treatment against the wishes of the patient (...) or their families. (shrink)

Coma, vegetative state, lock-in syndrome and akinetic mutism are defined. Vegetative state is a state with no evidence of awareness of self or environment and showing cycles of sleep and wakefulness. PVS is an operational definition including time as a variable. PVS is a vegetative state that has endured or continued for at least one month. PVS can be diagnosed with a reasonable amount of medical certainty; however, the diagnosis of PVS must be kept separate from the outcome. The patient (...) outcome can be predicted based on etiology and age. Using outcome probabilities and etiology as criteria, patients can be subdivided in 5 groups and reasonable management guidelines can be suggested. Three levels of care can be provided to PVS patients: high technology, supportive and compassionate care. Pragmatic options for the various subgroups of patients are suggested. Management decisions will remain difficult for both the family and the health-care team. The role of the physician in these difficult cases is to share the decision-making with the family. (shrink)