Assume for a moment that your 90-year-old mother has recently suffered a stroke. She is right-handed, and now she is unable to move her right arm and leg — they are worthless to her. She can make sounds, but she can't make herself understood. The condition has lasted two months and since there has been no sign of improvement, the doctor tells you she will never get significantly better. Until this time your mother has always been an active, independent person who lived on her own. Now she is completely dependent on others. 
Next, x-rays show your mother has a lung infection — a frequent problem with stroke patients. The doctor then calls you, her only surviving relative. "We can treat the infection with drugs and she'll probably get better in a week," he says. "When I say better, I mean she'll go on as she has — until some other germ comes along. Or I can deny her the medicine, in which case she'll probably die in three or four days. We can make those days comfortable by giving her painkillers and sleeping pills. Which course do you want me to follow?" Tough question, isn't it? On the one hand, you cannot bear to see your once vigorous mother living the painful, limited life to which the stroke has condemned her. On the other hand, you hate to be the one to decide to let nature take its course. I'll tell you which choice I would make in this theoretical situation. I'd say, "Don't give her anything to fight the infection. Keep her comfortable and let's see what happens; maybe she'll fight off the infection on her own and if she doesn't, she'll die a peaceful death. I don't want to be responsible for condemning my mother to a living hell." I can make this decision because I've gone down this road with patients many times. Recently I operated in vain on an eighty -year-old woman with cancer of the liver ... There was nothing I could do to relieve the problems the cancer had caused. She was an intelligent woman, without any close relatives, and a couple of days after the operation I sat down with her and explained the situation. "I can give you some anti-cancer drugs," I said, "but they will make you sick and cannot cure you. Similarly, I can give you fluids through a needle in your arm, which will keep you fed as your appetite slips away; the fluids might add a week or two to your life. Or I can withdraw all other treatment and just give you a vitamin pill, and we can see what happens. Personally, my recommendation would be the last choice. I'll keep you comfortable, and we'll see what happens." The patient elected to follow my advice and died peacefully, pain free, a fortnight later. Sometimes such a transparent decision is more difficult to come by. Recently I had a patient who suffered a severe stroke. He was completely unable to move and couldn't swallow anything. We gave him fluids for the first two weeks and then fed him through a tube which passed through his nose into his stomach. After three weeks he was still completely unconscious, and the tube caused him to have a constant, painful sore throat ... I talked to his four grown children and told them I thought we should insert a tube directly into his stomach through a small hole so he could be fed without so much pain. I also told them, "I can remove the tube and just let him swallow whatever he can. Chances are he won't live long, but he won't be in pain." No one wanted to take the responsibility for permitting an operation, yet no one would give permission to stop feeding the patient entirely. 
As a result, the poor man continued on for nearly three more months with a painful throat and frequent bleeding caused by sores in the mouth. He died of a major infection - a sad way to die. So what should responsible persons do when confronted with the necessity of such an enormous decision? What it all comes down to is common sense. For the 30 years I have been a doctor, and for hundreds of years before that, doctors and families have been quietly cooperating to decide what is best for a patient in the final phase of an illness. In 95 percent of the cases a sympathetic, reasonable decision can be made after appropriate discussion. In 5 percent of cases where such a judgment cannot immediately be reached, the proper decision will become apparent after a few days or weeks of basic treatment, observing the patient's progress. Let me sound one note of warning. Neither families nor doctors like to make life-death decisions. But there is no question that if either party insists on bringing in a so-called "neutral"; third party (usually some representative of the state or legal profession), not only will the process take longer, in many instances it will be more arbitrary and less sympathetic. What we are trying to avoid is neutrality; the only people with any qualification to decide are those who know the patient intimately and can put his or her interests first. If there's one place from which the interference of lawyers and government officials should be barred, it's from the rooms of critically ill patients.
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