Decisions to withhold or terminate treatment

Decisions to withhold or terminate treatment are common clinical dilemmas in patients dying from diseases of the nervous system. Decision making for such patients must be based upon ethical principles. Under the doctrine of valid consent and refusal, competent patients have the right to refuse life-sustaining therapies. For incompetent patients, this right may be exercised through their previously executed advanced directives or through appointed proxy decision makers. Physicians have the duty to assess the potential benefits and harms of various treatment options and to clearly communicate this information to patients and their proxies in a supportive manner. The authors illustrate the application of ethical principles in neurologists' management of patients in persistent vegetative states, dementia, and end-stage neuromuscular disease.