recent times have witnessed much turmoil regarding the ' life is sacred at any cost ' maxim .
current technology is capable of indiscriminately maintaining some of the vital functions of the body , but the same technology does not necessarily allow us to heal underlying disease processes .
an unintended side effect of modern technological advances has been the plausibility of maintaining moribund patients in a state of suspended animation for prolonged and sometimes indefinite periods .
also , advanced resuscitation techniques make it possible to convert death into life - in - death .
patients may be stalled in suspended animation ; they are not alive in the sense the we enjoy life but neither are they able to die as long as nutrition , hydration , ventilation , and perfusion are assured . in many cases reanimation of such patients
this conundrum is created because we must be prepared to apply life - sustaining technology to patients when the benefit appears to outweigh the risk and when there is a reasonable chance for an outcome that the patient would desire .
it frequently seems reasonable to buy sufficient time to see whether the disease will respond to aggressive treatment by instituting the most invasive life support technology .
however , if organ system failure is not reversible , then the reasoning behind life support technology becomes moot .
we must then be prepared to remove supportive technology when it appears that inevitable death is being delayed , rather than meaningful life prolonged .
the courts have repeatedly affirmed competent a patient 's authority to regulate their medical treatment , regardless of their reasoning . however , when the patient becomes incapacitated , family surrogates are granted authority to make decisions regarding treatment options because of their proximate knowledge of what the patient would have wanted before they became incompetent .
this position is based on the postulate that any attempt to interject physician paternalism into the surrogate decision - making equation is ethically unacceptable .
most rational surrogates are unwilling to continue life support after a reasonable trial has demonstrated that its benefit has passed the point of diminishing returns .
however , there is a continuing trend of surrogates demanding that moribund patients be kept on life support after prevailing medical opinions concur that there is no meaningful chance of reanimation . some reasons why this occurs are as follows : 1 .
physicians tell surrogates that they can make any decision they want as an open - ended ideal .
this puts them in the position of being buyers in a consumer 's market . by asking them to make a choice
an observer 's primal reaction to the vibrant external appearance of a body supported in an intensive care unit ( icu ) is radically different from that to a corpse on a morgue slab .
as long as the patient ' looks viable , it is emotionally easier to accept the pie in the sky bye and bye long shot cure ' .
if the patient can just be maintained comfortably for long enough , then a cure may eventually become possible .
3 . surrogates dislike being in a position of making decisions that directly result in the death of a loved one .
once life - supporting care is instituted , the patient has options for ' survival ' that they did not have before , even though they are dependent on ' life support ' .
there are now variables that decision makers control , and it is much easier to avoid decisions that may hasten death . instead of yielding to inevitable death , the potential now exists to manipulate it .
physicians do not have an exceptional track record in explaining end - of - life issues to patients and their families .
it is not uncommon for physicians to ask loaded questions in their quest for end - of - life decisions .
for example , ' this is your grandmother 's 17th transfer from a skilled nursing facility in 3 months for sepsis and respiratory failure , and now she 's in kidney failure as well .
what do you want to do : everything or let her die ? ' given that choice , most surrogates would opt for doing something rather than nothing , even if ' something ' perpetuated open - ended pain and discomfort .
the popular media , especially the tabloids , frequently feature anecdotal articles describing patients who have awakened after years of coma .
most if not all of these patients ' conditions have been embellished to generate public interest , and frequently subsequent investigators can not find these patients .
accordingly , some families feel that if life support systems can maintain vital signs for a day or a week , then ' suspended animation ' should be possible indefinitely , until a cure is found .
the notion of ' medical futility ' as an end - stage process in which vital signs can not be supported further is poorly understood by both physicians and surrogates .
in fact , any medical treatment capable of sustaining hemodynamics , ventilation , and metabolism is not technically futile if it achieves that limited goal .
therefore , if a patient in a progressive , inevitable death spiral is placed on mechanical ventilation , it is not technically futile if vital signs are sustained , however briefly .
it is medically inappropriate but not technically futile . under the current rules , the only test of futility
is that embodied by the question , ' will this treatment result in sustained life ? ' if the answer is ' yes ' , then virtually any treatment is fair game , even if it will do nothing to revitalize the patient .
perhaps the most effective way of dealing with strong familial incentives to tread the path of least resistance in end - of - life care is twofold .
first , in end - of - life issue discussions , we must strive for ' consensus without consent ' .
discussions with surrogates should strive for concordance and understanding but not extend to soliciting their consent for medically inappropriate care .
second , we should strive to emphasize what streat and coworkers   termed , ' the large risk of unacceptable badness ' , rather than a vanishingly small potential for benefit .
there are far worse things than death , and many of them occur in icus when futility maxims are circumvented .
there is a population of icu patients who will die no matter what treatment is rendered them .
medically inappropriate care causes pain , suffering , and discomfort . the fundamental maxim for these patients should be comfort .
 when patients or their families rarely request inappropriate end of life care in the icu for capricious reasons . 
 end of life treatment decisions that only prolong discomfort and death are usually emotional and based on unrealistic expectations . 
 i explore some of those reasons in this paper . 
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