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Editorials: POINT/COUNTERPOINT EDITORIALS |

Point: The Ethics of Unilateral “Do Not Resuscitate” Orders : The Role of “Informed Assent”

J. Randall Curtis, MD, MPH, FCCP; Robert A. Burt, JD
Author and Funding Information

Affiliations: Seattle, WA ,  New Haven, CT ,  Dr. Curtis is Professor of Medicine, Departments of Medicine and Medical History and Ethics, University of Washington; and Professor Burt is The Alexander M. Bickel Professor of Law, Yale University Law School.

Correspondence to: J. Randall Curtis, MD, MPH, FCCP, Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, Box 359762, 325 Ninth Ave, Seattle, WA 98104-2499



Chest. 2007;132(3):748-751. doi:10.1378/chest.07-0745
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Death is prevalent in the ICU. A study1 suggests that approximately 20% of deaths in America occur in an ICU. Many investigators24 have shown that the majority of deaths in the ICU involve withholding or withdrawing life-sustaining therapies. There is growing consensus regarding the importance of shared decision making in the ICU, where clinicians and family members work together to make decisions about life-sustaining treatments.5 However, there remains considerable controversy over the appropriate role of unilateral decisions by physicians to withhold or withdraw life-sustaining treatments. In 1991, the American Thoracic Society6 defined a life-sustaining intervention as futile “if reasoning and experience indicate that the intervention would be highly unlikely to result in a meaningful survival for that patient” and argued that physicians are not obligated to provide such treatments. The Society for Critical Care Medicine came to similar conclusions.7 There have been cogent descriptions of the definition and value of this principle in medical decision making89 and evidence that the principle of futility is currently being used in clinical practice in the United States10 and around the world.11 However, there have also been cogent arguments made against the use of the futility principle,1214 and a landmark article proclaimed the “fall of the futility movement” based on these arguments.14 Currently, there is no general professional consensus about the value and pitfalls of unilateral clinician decision making based on the principle of medical futility. We hope to move this debate forward by reframing the role of unilateral decision making within the context of clinician/family communication and shared decision making about withholding and withdrawing life-sustaining treatments. We propose incorporation of the notion of “informed assent” for some types of these decisions.

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