• John M Luce.
• Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, USA.
• Crit. Care Med. 2002 Apr 1; 30 (4): 775-80.

ObjectiveTo illustrate some of the difficulties encountered in the transition from restorative to palliative care and in the pursuit of patient autonomy in the intensive care unit.DesignA review of the cases of three patients who asked that life support be withheld or withdrawn, and a discussion of the legal and ethical implications of these cases.SettingA surgical intensive care unit in an academically affiliated public hospital serving as a Level I trauma center.PatientsThree adults with severe injuries who lacked legal surrogates and lost the ability to make medical decisions.InterventionsCare from the attending surgery and consultative critical care services, in addition to consultations from the psychiatry service and the hospital ethics committee.Main ResultsAll three patients died after life support was withheld or withdrawn, but not without conflicts among the various services. In two cases, decisions that the patients may or may not have agreed with were made for them by their physicians. In the third case, the patient was not consulted after his clinical situation changed.ConclusionsPatients' wishes change and are difficult to know, and even when they are known, physicians may have difficulty honoring them. Nevertheless, patient autonomy should be respected whenever possible in the intensive care unit.

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