Clinical Commentary

Making Decisions About the Forgoing of

Life-sustaining Therapy
JOHN M. LUCE
Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, San Francisco, California

The incidence of withholding and withdrawal of life support from critically ill patients has increased
to the extent that these practices now precede well over half of all deaths in many intensive care
units (ICUs). Although the forgoing of life-sustaining therapy is ethically acceptable and clinically de-
sirable in certain instances, and although physicians do not have a responsibility to provide futile care
even if a patient or surrogate insists on it, they must be cautious in exercising their influence, if not
authority, over patients and surrogates in prompting the withholding and withdrawal of life support.
Such caution is particularly indicated because managed care has made patients suspicious of health-
care institutions and physicians who are rewarded for restricting access to care. Most patients and
surrogates agree with reasonable physician recommendations to forgo life-sustaining therapy. When
they do not agree, physicians should not limit care on the basis of their own personal notions of futil-
ity, but should instead rely on institutional or multiinstitutional futility policies. Such policies should
be developed by health professionals, patients, community leaders, and, when appropriate, partici-
pants in managed-care organizations. They should specify which ICU interventions are beneficial, ad-
dress potential conflicts of interest, and be available to persons who could use such information in se-
lecting the source of their care. Luce JM. Making decisions about the forgoing of life-sustaining
therapy. AM J RESPIR CRIT CARE MED 1997;156:1715–1718.

Ten years ago, my colleagues and I undertook an observa-
tional study of the withholding and withdrawal of life support
from critically ill patients in two intensive care units (ICUs) in
hospitals affiliated with the University of California, San Fran-
cisco (UCSF). We did so because we believed that life-sustain-
ing therapy was frequently forgone in our ICUs, and that this
practice was ethically acceptable and clinically desirable if it
reduced unnecessary suffering in patients who were unlikely
to benefit from further treatment. We also hoped that physi-
cians elsewhere might become more actively involved in man-
aging the deaths of their patients after reading about our ex-
perience. We learned and subsequently reported (1) that
withholding and withdrawal of life support occurred in 51% of
the patients who died in our ICUs during a 1-yr period in 1987
and 1988, a larger percentage than we anticipated at the time.
Physicians whom we interviewed in this study recom-
mended that life-sustaining therapy be forgone primarily be-
cause their patients were dead by neurologic criteria or had a
poor prognosis as determined by the physicians’ clinical expe-
rience and knowledge of the medical literature. All but 2% of
(Received in original form May 2, 1997 and in revised form July 21, 1997)
Supported by institutional funds of the University of California, San Francisco.
Correspondence and requests for reprints should be addressed to John M. Luce,
M.D., Division of Pulmonary and Critical Care Medicine, San Francisco General
Hospital, 1001 Potrero Avenue, Room 5K1, San Francisco, CA 94110.
Am J Respir Crit Care Med Vol 156. pp 1715–1718, 1997
patients or surrogates agreed with these recommendations, al-
though reaching such agreement frequently required several
days. Support was continued for those few patients or surro-
gates who insisted upon it. For the other patients, cardiopul-
monary resuscitation (CPR), mechanical ventilation, and va-
sopressors were the therapies most frequently withheld and
withdrawn. Of those patients who were not brain dead, 70%
received analgesics and sedatives as other care was discontin-
ued. Although our observations were limited to two institu-
tions affiliated with UCSF, we speculated that forgoing life-
sustaining therapy would become more common throughout
the United States because policy makers and the public were
increasingly concerned about the uncertain benefits, the possi-
ble harm, and the high cost of critical care.
Five years after our initial study, we performed a follow-up
study in the same two ICUs. We found and then reported (2)
that forgoing of life-sustaining therapy preceded death in 90%
of patients who died in the ICUs during a 1-yr period in 1992
and 1993. Death according to neurologic criteria, and a poor
prognosis, expressed in terms of futility, were again the rea-
sons cited by physicians for recommending that life support be
withheld or withdrawn. In 56% of cases in which futility was
cited, physicians judged that patients had “absolutely” no
chance to leave the ICU alive. However, in 44% of cases, phy-
sicians applied the concept of futility despite an estimate of
ICU survival of between 1% and 50% (median: 5%). Again,
almost all patients or surrogates agreed with physician recom-
mendations to limit care, and care was provided for patients or
1716 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
surrogates who requested it. However, as was not the case in
our previous study, do-not-resuscitate (DNR) orders were
written without the consent of the surrogates of several pa-
tients for whom other kinds of life support had been contin-
ued. We considered the writing of these DNR orders justifi-
able, and we questioned whether some physicians were not
too passive in permitting the exercise of technology to persist
for so long in hopeless cases.
In a subsequent article (3), I argued that physicians do not
have a responsibility to provide futile or unreasonable care
even if a patient or surrogate insists on it. My argument was
based on the belief that physicians need not merely furnish all
services asked of them, but that they have a professional obli-
gation and a social sanction to provide only therapies that are
beneficial, to avoid harm, and to allocate medical resources
wisely. Although physician pursuit of beneficence, nonmalefi-
cence, and distributive justice may conflict with patient auton-
omy, such conflict has not prevented physicians from acting
unilaterally in limiting life-sustaining treatment. This practice
was demonstrated by Asch and colleagues (4), who surveyed
members of the Critical Care Section of the American Tho-
racic Society (ATS) in 1990 and found that over 80% of re-
spondents had withheld or withdrawn life support on the basis
of futility. Many physicians reported forgoing care without the
consent or knowledge of patients and surrogates, and some re-
ported doing so over patients’ or surrogates’ objections.
In 1994, Thomas J. Prendergast, M.D., and I asked physi-
cians in 167 institutions associated with fellowship programs in
Pulmonary and Critical Care Medicine and just Critical Care
Medicine to classify all deaths that occurred in their ICUs over
a 6-mo period into one of five defined categories (5). With 126
ICUs at 107 of the 167 sites (64%) reporting, we amassed data
for more than 71,000 admissions and some 6,100 deaths (9%
overall mortality rate): 25% of deaths followed full ICU care
and failed CPR, 23% of deaths occurred in patients who re-
ceived full ICU care excluding attempted CPR, 13% of deaths
occurred in patients who had some form of life support other
than CPR withheld prior to their deaths, 33% of deaths fol-
lowed the withdrawal of life support, and 6% of patients were
brain dead. When the first and last categories were totaled,
69% of the ICU deaths were found to have followed the for-
going of CPR and other forms of life-sustaining therapy.
At first glance, the results of this recent study suggest that
withholding and withdrawal of life support have become so
commonplace in American ICUs that they are de facto stan-
dards of care. Nevertheless, significant variability was found
among surveyed ICUs in terms of mortality rate (from 2% to
45%), failed CPR (from 4% to 79% of deaths), and willing-
ness to withdraw support (from 0% in six ICUs comprising ap-
proximately 2,700 admissions and 200 deaths to 71% in other
ICUs). This variability could not be explained by differences
in the kind (e.g., medical versus surgical), size, or geographic
location of the ICUs. Some of it might have been due to differ-
ences in the severity of illness of patients in the ICUs, which
we did not measure. However, most of the variability proba-
bly related to differences in the beliefs and behavior of physi-
cians, as has been suggested by another study (6). Whatever
its explanation(s), the variability precludes the conclusion that
true practice standards exist in the area of forgoing life-sus-
taining therapy, although such forgoing clearly has become
common. It also raises the question of how to regard outliers
at both ends of the clinical spectrum: those ICUs in which
withholding and withdrawal of life support are customary and
those in which they occur rarely if at all.
As a physician in an ICU at the “customary” end of the
spectrum, I still believe that our approach to forgoing life-sus-
VOL 156 1997
taining therapy at UCSF is generally acceptable and desirable.
Nevertheless, I often ask myself whether we have gone too far
in recommending that life support be withheld or withdrawn
from some of our patients for whom further care would not be
futile in a stringent sense of the word. I also wonder whether
we have been too zealous in promoting these practices in
other institutions, particulary because in the process we have
challenged patient autonomy by suggesting that care could be
forgone in certain circumstances without the agreement of pa-
tients or their surrogates. Challenging patient autonomy prob-
ably was important at one point in the evolution of our profes-
sion’s view of limiting care for certain critically ill patients,
because physicians were just becoming comfortable with the
ideas that not all demands upon them must be met and that
life, especially nonsentient life, need not be supported at all
cost. Nevertheless, I sense that many of my colleagues in San
Francisco and other cities have realized that we must be very
cautious in exercising our influence, if not authority, over pa-
tients and their surrogates in prompting the forgoing of life-
sustaining therapy in the ICU.
Some of the colleagues I refer to have been members of
one or both of two bioethics task forces established by the
ATS in recent years. The first task force was convened in 1989
and chaired by Paul N. Lanken, M.D. After considerable de-
liberation, it recommended that patient requests to withhold
or withdraw life support should be respected, and that surro-
gates should be identified to help make decisions about life-
sustaining therapy when patients lack decision-making capac-
ity. In addition, however, the task force stated that a life-sus-
taining medical intervention can be limited without the con-
sent of patient or surrogate when the intervention is judged to
be futile, and that health-care institutions have a responsibility
to promote ethically sound decision making regarding life-sus-
taining therapy. Included among these responsibilities are writ-
ten policies defining the circumstances in which it is accept-
able to withhold or withdraw life support, and those in which
there may be limits to a patient’s or surrogate’s directives ei-
ther to forgo or to request life-sustaining interventions. The task
force’s recommendations, which were adopted by the ATS
Board of Directors in 1991, were subsequently published in
the American Review of Respiratory Diseases (7) and the An-
nals of Internal Medicine (8). They remain the boldest state-
ment by any professional medical society of which I am aware
on the prerogatives of physicians and health-care institutions
in restricting the application of critical care.
In 1993, a second ATS Bioethics Task Force was convened
under the leadership of Dr. Lanken and Peter B. Terry, M.D.,
to develop recommendations for the fair allocation of ICU re-
sources. Much of this second task force’s first meeting, in De-
cember 1993, was devoted to a discussion of how President
Clinton’s plans for health-care reform would affect ICU re-
source allocation. Several articles were distributed as back-
ground reading, including publications on medical triage and a
draft of an article I had prepared in advance of the meeting. In
this draft and in the Clinical Commentary (9) that was subse-
quently published in the American Journal of Respiratory and
Critical Care Medicine, I argued that the President’s goals of
cost containment and universal access to basic health care
could only be realized by restricting the use of marginally ben-
eficial services, including some ICU care, and by balancing
physicians’ unrestrained advocacy for individual patients with
a proportional advocacy for the entire population. I do not
know whether the task force members accepted my ideas at
the time. However, I remember clearly that the task force con-
sidered rationing of ICU services likely, and perhaps desirable
if marginally beneficial ICU care was restricted, and wanted to
Clinical Commentary
provide an ethical and practical framework for such rationing
if and when it was required.
More than 3 years have passed since that first meeting, and
the task force’s recommendations, which were adopted by the
ATS Board of Directors in March 1997, appear in the October
1997 issue of the American Journal of Respiratory and Critical
Care Medicine (10). Triage is mentioned in the recommenda-
tions, along with the idea that medically appropriate patients
should be admitted on a first-come, first-served basis when de-
mand for ICU beds exceeds supply. The recommendation also
is made that marginally beneficial ICU care can be restricted
on the basis of high cost relative to benefit, but that decisions
to limit care should be made only by explicit institutional poli-
cies that reflect a social consensus in support of such limita-
tions. Other recommendations are that patients should have
equal access to ICU care regardless of their personal and be-
havioral characteristics, that ICU care should be equally avail-
able regardless of patients’ ability to pay, and that patients and
the public should be informed of financial incentives for limit-
ing ICU care by physicians or health-care institutions. Among
the basic principles underlying these strong recommendations
are that each individual’s life is valuable, and equally valuable
with those of others, and that access to ICU care, when medi-
cally appropriate, is an essential part of a basic package of
health-care services that should be available to all.
Once again, the ATS Bioethics Task Force has come up
with a bold statement, but it is not what I would have pre-
dicted 4 years ago. What accounts for the statement’s deempha-
sis on rationing critical-care services and its emphasis on secur-
ing equal access to the ICU? Although the cochairmen and other
task force members may offer other explanations, I suspect
that they would agree that changes in health care in the United
States have inspired, if not mandated, the ATS’s strong posi-
tion in support of the right of all patients to receive medically
appropriate ICU care. President Clinton’s goal of universal
access to health services has not been realized since the task
force first met; in fact, more Americans lack health insurance
today than ever before. Managed care, which many hoped
would contain costs without compromising quality, has be-
come broadly identified as a tool for increasing corporate prof-
its by denying medical services. Whether this is true or not, the
traditional physician–patient relationship has been increas-
ingly complicated by the presence of a third party: the payor
that seemingly seeks to restrict access to health care. As a re-
sult, patients have become increasingly suspicious of their
health-care institutions and of those physicians who are re-
warded for restricting access. In this environment, it is entirely
appropriate that the ATS Bioethics Task Force and the ATS
Board of Directors have taken their stand.
In keeping with both ATS statements, in light of the cur-
rent health-care environment, and in accord with my own
changes in sentiment, I propose that physicians reconsider cer-
tain aspects of how they withhold and withdraw life support
from the critically ill. I still believe that we can and should rec-
ommend that life-sustaining treatment be forgone if we con-
sider it futile because the patient’s prognosis is poor. Futility
in this context need not be defined in narrow physiologic
terms, such as an inability to raise the blood pressure by ad-
ministering vasoactive agents. Rather, it should be seen as em-
bracing a combination of quantitative (e.g., the probability of
survival following a given medical intervention) and qualita-
tive (e.g., survival should include an acceptable quality of life)
dimensions, as advocated by Schneiderman and colleagues
(12). This definition of futility is close to the concept of “inad-
visable” treatments advanced by the Ethics Committee of the
Society of Critical Care Medicine (11).
1717
Curtis and associates (13) have demonstrated that even
when a quantitative and qualitative definition of futility is
used, physicians may misunderstand the probability of sur-
vival following an intervention such as CPR, and may fail to
determine what quality of life is acceptable to their patients.
These authors require that quantitative futility be based on a
very low probability of survival, perhaps lower than 1%, and
that the recommendation to limit care be preceded by a discus-
sion of quality-of-life issues between physicians and patients
or their surrogates. These requirements seem appropriate to
me. I also believe that recommendations made after these re-
quirements are met need not bear any relationship to ration-
ing or resource allocation; they merely reflect the physician’s
obligation to seek benefit and do no harm.
In most instances, patients and surrogates accept physician
recommendations to limit care if sufficient time is afforded
them to consider these recommendations (1, 2). Nevertheless,
on rare occasions, they insist that care be continued, and can-
not be dissuaded from this position, presumably because they
disagree with the prognosis we have provided them. When this
occurs, I believe that we should not withhold or withdraw life
support on the sole basis of our personal notions of futility,
but instead should rely on institutional or multiinstitutional
futility policies. Although their input is desirable, administra-
tors, even if they are physicians, should not be allowed to im-
pose futility policies that serve primarily to protect their busi-
nesses’ bottom lines. Rather, the policies should be developed
by practicing physicians, nurses, and other health profession-
als in concert with patients, community leaders, and, when ap-
propriate, participants in managed-care organizations. This
approach would replace payors in now tripartite physician–
patient relationships with representatives of either the com-
munity in general or of the subscribers in an individual health
plan. Futility policies crafted in such a fashion should specify
which ICU interventions are beneficial and which are not.
They should address potential conflicts of interest issues be-
tween physicians who are paid on a capitated basis and the pa-
tients for whom they care. Such policies should also be avail-
able in advance to persons who could use such information in
selecting their care from a particular hospital, medical group,
or health-care plan.
One model of a multiinstitutional policy (14) on futility has
been developed by representatives of major hospitals in Hous-
ton, Texas. Under this policy, when a physician determines
that an intervention is inappropriate but a patient or surrogate
insists that it be provided, the physician must first discuss the
reasons for his or her judgment, the possibility of transferring
care without abandoning the patient, and alternative treat-
ments such as palliative care. If agreement is not reached at
this point, the physician must obtain a second opinion from
another physician who has examined the patient, and must
present the case before an institutional review body. If the re-
view body affirms that the intervention is inappropriate, the
intervention is terminated, a plan of alternative care is estab-
lished, and interinstitutional transfer of the patient to another
physician, in order to provide the intervention that has been
deemed inappropriate, is not allowed. On the other hand, if
the review body finds that the intervention is appropriate, or-
ders to terminate the intervention are not recognized as valid
without patient or surrogate assent.
The Houston collaborative policy is limited in that it was
developed by institutional representatives without explicit
community involvement, as its authors (14) acknowledge. The
legal standing of such a policy is also uncertain, in light of
court decisions such as that concerning Baby K (15), wherein
the court mandated continuation of life support for an anen-
1718 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
cephalic infant in response to parental requests; or that involv-
ing Helen Wanglie (16), in which the court refused to appoint
a surrogate other than the patient’s husband who might agree
to a limitation of the patient’s care; and that of Catherine Gil-
gunn (17), whose physicians were absolved of liability after
they withdrew life support over the objections of the woman’s
daughter. Case law is thus incomplete and contradictory in
this area, and the medical profession cannot wait for such law
to develop before clarifying its own values and methods for re-
solving conflict between patients and providers.
Furthermore, it is not clear whether the Houston collabo-
rative futility policy is workable in the ICU environment,
where decisions must often be made quickly, or that physi-
cians will follow it rather than openly or surreptitiously limit-
ing care on their own. Nevertheless, the policy represents a
commendable approach in balancing patient autonomy and
professional and institutional integrity, and its very presence
seems to have prompted the resolution of disputes before insti-
tutional review bodies are required (B. A. Brody, personal com-
munication, April 25, 1997). By shifting decision-making from
the patient, physician, and payor to a group level, futility poli-
cies such as that adopted in Houston should move us closer to
a social consensus on the issues of what is truly beneficial and
how limited resources should be allocated. In the process, they
should help restore public confidence in physicians and health-
care institutions, a confidence that is severely threatened today.
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