Lessons Learned From the Terminally, Critically Ill Patient Who Demands to Live as Long as Possible.

A 67-year-old man with metastatic pancreatic cancer was admitted to the hospital for terminal care. The patient requested intensive medical support in order "to live as long as possible." Management goals included preserving end-of-life autonomy; therefore, life-extending treatments were delivered as he had adamantly requested. Simultaneously, there was agreement among physicians that futile treatments were unwarranted. Discussions with the power of attorney did not alter medical management. Elements of a "Fair Process Approach to Futility," published in March 1999 by the American Medical Association (AMA) Council on Ethical and Judicial Affairs, were utilized in an attempt to achieve conflict resolution. Medical subspecialist and ethics committee consultations had contributory roles in resolving conflict between the patient and patient surrogate and the patient's physicians. This case offers the following lessons: 1.Potential conflicts in end-of-life care management philosophy should be addressed early in the patient-physician relationship. 2.Patients and surrogates should be made aware that physicians are under no obligation to provide futile care. 3.Futile or medically inappropriate care should not be offered "theoretically" with the expectation that it will be refused. 4.The Advance Directive can guide end-of-life care but does not substitute for physician judgements. 5.A "fair process" end-of-life care management algorithm can provide limited structure to the process of patient-physician deliberation and conflict resolution.