Dr. Fronduti raises an important issue. I believe that a (misplaced) fear of litigation caused the situation I described to arise. Any decision we make in patient care, however, may put us in a perilous position—especially if the patient or surrogate is not informed. All decisions taken unilaterally are risky, not only those involving CPR. The patient or surrogate must be given the opportunity to question, learn, to assimilate, and to object when discussing treatments. This does not mean that treatment decisions are theirs alone or that they should necessarily be posed as questions. Cardiopulmonary resuscitation is unique in that physicians commonly feel that they must provide it unless they are specifically given permission not to. The consequence is that we offer this intervention whether or not we feel it is indicated. This very offer may impart a legitimacy to CPR that is wholly unintended and can lead to patient suffering, provider frustration, loss of morale, and family guilt. I maintain that when we are not offering equally ineffective interventions, we should not offer CPR—but this does not mean that we should not discuss it.

None of us does "everything" for any patient. We avoid doing things that don't work. Occasionally, we do confront patients or families who demand ineffective treatments. When we talk about treatments in this context, however, we try to approach them as opportunities for discussion and education, not to ask permission to withhold such treatments. In this case, the patient's wife was relieved to be told that we no longer considered CPR to be a legitimate treatment option rather than to be asked whether she would assent to withholding it. This conversation occurred just before the patient's death. Had she responded otherwise, we might have faced the dilemma with which Dr. Fronduti is concerned. Under threat of lawsuit, I suppose, we may have been persuaded to do CPR despite our belief that it offered no benefit to the patient, just as we may have initiated dialysis under a similar threat. The point remains that, by approaching CPR as we had other treatments, we avoided suffering for both the patient and family. I believe this lesson is widely applicable.