The evolution of the patient’s clinical course usually indicates when the time has arrived to discontinue life-sustaining treatment and to allow a patient to die. However, time is not always on the physician’s or the patient’s side. The conscious, alert, and ventilator-dependent patient certainly presents one of the greatest and most difficult challenges to clinicians and family in deciding when to stop support that could prolong life indefinitely in an intensive care unit. The term ‘entrapment’ has been used to describe this situation that may occur more frequently in spinal cord injury and neuromuscular disease than in other clinical conditions. Entrapment may also occur outside the context of respiratory support, for example, in clinical situations marked by a slowly cascading series of organ failures and infections.

There is no one single ethical protocol that can cover these situations. The following considerations, however, offer a direction for difficult decisions. First, there is no clinical or moral obligation for physicians and family to adhere to a treadmill of increasing therapy and diminishing returns for a patient who will, in all probability, never be freed from a regimen of intensive care. Second, there is no ethical difference, and it is also increasingly recognized that there is no legal difference, between not starting and stopping life-prolonging treatment. Third, the purpose of resuscitation, respiratory support, and other emergency and intensive care measures is to return a person in acute collapse to some reasonable measure of normal human life. Intensive care treatment has reached its limits when its only result is to entrap a patient into permanent bondage and residency in an intensive care unit. Intensive care has reached its limits, and may be stopped, when it can do little more than totally tie the patient’s time and energy to the procedures of survival. Fourth, it is not always possible, but it sometimes happens that patients are able to understand their predicament and are able also to help family and physicians with the difficult decisions that have to be made.

Case study A 10-year-old boy, neurologically damaged but cognitively unimpaired after an automobile accident, had already suffered several episodes of respiratory failure and would continue to do so indefinitely. This little boy, while still on respirator after his last respiratory arrest, clearly told his parents and doctor that he wanted to go home and was altogether too fatigued by the whole process to ever want to be resuscitated again. Nancy, B., a 25-year-old woman in Quebec, afflicted with extensive muscular atrophy resulting from Guillain-Barre syndrome, initiated the discussion and deliberation that eventually elicited Superior Court agreement with her request to stop the respirator on which she would be dependent for breath and life for the rest of her life.

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