Discontinuation of mechanical ventilation at end-of-life: the ethical and legal boundaries of physician conduct in termination of life support.

End-of-life care in the ICU generally encompasses both the withholding and withdrawal of life support and the administration of palliative care. There is little practical distinction in the specific technology or life-support modality that is limited or removed with respect to the subsequent medical, ethical, or legal analysis. The important ethical issues pertinent to end-of-life care in the ICU at the point-of-life support discontinuation are: (1) the distinction between allowing patients to die in accordance with their wishes and causing them die, (2) the fine line between respecting a patient's wish to die with dignity and control and the risk of subsequent allegations of euthanasia or physician-assisted suicide, and (3) the adjunctive use of medications that simultaneously provide comfort but also may hasten death. The medical and legal issues are summarized, and an algorithm for the discontinuation of mechanical ventilatory support at the end of life is presented.