Quality of life: a focus on the patient's total good

The quality-of-life factor used in making difficult decisions about life-sustaining treatment should refer to the patient's definition of meaningful survival. The significance of this is founded on theological convictions that respect life's value and promote its meaning according to the ability to actualize life's potential, especially through love. The appropriateness of quality-of-life criteria is entailed in the principle of beneficence: doing good for the patient. Beyond medical good, this must include each aspect of the patient's total good--autonomy, preferences, and ultimate (spiritual) good. The proportionate-disproportionate distinction exemplifies this by weighing treatment effects against patient benefits. The difficulty in applying the quality-of-life factor primarily involves who determines the criteria, as answered by one of three approaches: The "gold standard" gives priority to informed patients capable of deciding for themselves. The "silver standard" is the proxy judgment substituting for patients' previously communicated wishes. The "bronze standard" is the judgment made in patients' best interests when no wishes have been expressed. Healthcare delivery can address quality-of-life considerations using five guidelines: 1. Respect the wishes of informed patients capable of decision making. 2. Treat incompetent patients as similar patients have chosen to be treated. 3. Act to restore patients' capacity for meaningful relationships. 4. Determine if treatment yields a reasonable balance between treatment effects and patient benefits. 5. Refer doubtful treatment decisions to an institutional ethics committee.