Understanding the key areas of clinical decision making at the end of life.

The ability of medical science to prolong biological life through the use of technology raises the question of how far physicians should go in treating the terminally ill patient. In clinical decision making involving the dying patient, physicians, patients and families bring various perceptions and interpretations to the situation. These different realities must be negotiated in order to define the meaning of the situation and the meaning of various medical technologies. The patient's demise becomes a negotiated death, a bargaining over how far medical technology should go in prolonging life or in prolonging death. A case study of the process of ethical decision making in the foregoing of life-supporting therapy in an intensive care setting is presented and analyzed. The decision making process in this case follows a 'cascade' pattern rather than a controlled, reflective model. While ethicists view the withholding and withdrawing of life-supporting treatment as morally equivalent, physicians tend to make a distinction based on the perceived locus of moral responsibility for the patient's death. In the author's interpretation the moral responsibility for the patient's death by withdrawing treatment is shared with family members, while the moral responsibility for the patient's death by withholding treatment is displaced to the patient. The author suggests that an illusion of choice in medical decision making, as offered by the physician, begins a negotiation of meanings that allows a sharing of moral responsibility for medical failure and its eventual acceptance by patient, family and physician alike.