In the study by Schneiderman and colleagues [1], the lack of a significant difference between patients executing advance directives and those not offered the instrument may have resulted from physicians allowing patient autonomy only to the extent that they agreed with the decisions. Two recent case histories are illustrative.

A 70-year-old man with a history of alcoholic cirrhosis and delirium tremens was admitted for detoxification and was prophylactically treated with a benzodiazepine. He developed a stable period of decreased responsiveness despite discontinuing benzodiazepine therapy. The attending recommended percutaneous gastrostomy feeding and placement in a nursing home. His wife, the patient's durable power for health affairs, refused percutaneous gastrostomy placement and asked that the patient's Dobhoff feeding tube be removed and that the patient be transferred to the palliative care unit. The attending flatly refused. An ethics committee consultation was required to negotiate the impasse. In accordance with the patient's living will and the wishes of his wife, the patient was transferred to the palliative care unit, where he died 2 days later.

An 80-year-old man came to the emergency room with chest pain. He had cardiorespiratory arrest and was resuscitated, intubated, and transferred to the intensive care unit. After a prolonged period of mechanical ventilation, he was extubated and transferred to a general medical ward. He made the housestaff aware of a previously executed living will and expressed his desire for no further aggressive therapy and for hospice placement. His attending physician of many years was adamantly opposed. The conflict was resolved by changing the care of the patient to a different physician, who acceded to the patient's request.

Since the enactment of the Patient Self-Determination Act, patients have been encouraged to express their treatment preferences. For many physicians this creates conflict. These two cases required extraordinary administrative effort and diplomatic skill to resolve, but I suspect that patients or their families commonly do not assert their preferences to such a degree as to cause conflict. Unless physicians are willing to tolerate patient decisions with which they do not agree, patient self-determination will be merely a buzzword.