In general, opinion as usually presented by newspapers and television, and also by patient directives, is that the physician should be instructed to 'stop all treatment when prognosis is fatal'. Nobody wishes to undertake futile acts, but how can one decide when an act is futile?

Futile acts are described as acts that are ineffective and incapable of achieving a desired result or goal: continuation of treatment could allow the patient to exist in a vegetable state, but would not have the capability of restoring sentient functions and individual personality. In the medical literature, there has been a change from the concept of futile care to the concept of reasonable care; this is an evolutionary, but dangerous, progression within medical ethics ( Civetta 1996). This change may reflect an ethical change within society at large, away from the moral authority of physicians and medical paternalism. However, the question remains as to how far one should be allowed to drift from traditional medical ethics. Admittedly, medical ethics is no longer viewed as an immutable framework of absolute truth or the province of physicians alone.

The current state of generally accepted ethical opinion and the view of the general public as to how to proceed in such situations must be respected and integrated in the decision-making process.

In practice, all the physicians and nursing staff in an intensive care unit (ICU) must be capable of abandoning treatment in certain situations. A consensus shoud be established and local guidelines, consistent with general ethical principles, must be available in written form in the ICU and strictly followed when making major decisions in special cases.

Following total acceptance of the decision to stop treatment, life-support measures such as mechanical ventilation, hemodialysis, administration of vasoactive drugs, etc. should be withheld or withdrawn if their continuation only serves to prolong the process of dying for the patient. This also applies to patients with an 'apallic syndrome'.

The ability to make a rational decision about whether or not to stop treatment depends on the ability to make a correct diagnosis, to understand the implications of the diagnosis for the future course, and to communicate this information to the patient's proxies.

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