Orchestrating a dignified death in the intensive-care unit

Approximately 2 million people die in the United States each year, 80% of them in acute- or chronic-care institutions. Physicians now have at their disposal interventions that can postpone death in almost every instance. In these circumstances the critical-care physician cannot avoid the responsibility of orchestrating death by balancing factors such as the patient's autonomy and best interests, medical uncertainty and futility, and notions of "passive" (permissible) and "active" (forbidden) euthanasia. Pressures to make decisions unilaterally and without patient input threaten to undermine important physician/patient/family dialogue. On the other hand, the fact that medical resources are becoming increasingly expensive and scarce will inevitably lead to rationing. The critical-care physician will be caught in the middle--orchestrating clinical care to balance the interests of individual patients and families against those of the larger community.