Autonomy is one of the four main principles of medical ethics, namely to respect the autonomy of the patient, to cure, not to harm, and to redistribute resources adequately. The increasing tendency to include the patient's wishes in medical decisions is well recognized. In the ICU, where it is frequently impossible to communicate with the patient, the increasing existence of written instructions is welcomed and they must have a strong influence on medical decisions.

The right of self-determination is valid in all patients ( World Federationf 1.992 ). In principle, the critically ill patient in the ICU is accounted competent to judge. However, restrictions due to his or her acute illness with severe pain, difficulty in breathing, or an exceptional mental state must be taken into account. If the patient is not fully competent to judge, his or her presumptive wishes are decisive ( Smediraeta/ 1990); his or her own written instructions and information from proxies or pretreating physicians should be respected. Patients' directives must be correctly formulated with the correct date and a hand-written signature. Their liability depends on the precision of the contents of the directive, how long ago it was written, and the putative possibility of foreseeing the present emergency situation at the time of writing.

In rare cases, the medical decision might deviate from that intended by the patient, particularly in the management of crisis (e.g. attempted suicide). There are no general rules for such delicate and individual situations. Any decision based upon the patient's wishes or written will must be compatible with the conscience of the person who has to perform it in practice (A§£h.eLal 1995); withdrawal of life-supporting measures must be carried out by the responsible physician.

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