Autonomy in the intensive care unit: the refusal of treatment.

How to act in intensive care environments so that whatever is done for patients will be seen by them, then or in the future, to be in their own best interests is the problem presented by the need to defend patients' autonomy. Obstacles to patients' choice include abrogation of choice by doctors, the difficulties of discovering what patients actually wish for themselves, and the rapidly changing clinical circumstances typical of critical care. Many of these problems are obviated by discussing choices before emergencies arise with patients whose illnesses or planned surgery make the need for resuscitation a realistic possibility. Such discussions require careful delineation of the goals of resuscitation.