Even if further treatment is clearly futile, worried families can have difficulty accepting that a loved one in intensive care will not make it through, several members of hospital ethics committees said at Georgetown.
"It's a tough one," said David Harness, Protestant chaplain at Baltimore's University of Maryland Medical Center.
"Rationally, you can understand there is brain death while the body is still functioning -- but it's difficult on an emotional level to separate those out."
Cheryl Fallon, a nurse manager at the intensive care unit in Queen's Hospital in Honolulu, was part of an ethics committee that decided it was futile to maintain daily blood transfusions for a woman just about to die from leukaemia.
"The family went to another hospital and asked their ethics committee, which recommended they continue," she said. "So our attending physician continued them. She died two weeks later."
While that was exceptional, patients and families often find ways to continue treatment hospital staff might consider futile.
"The two biggest manipulation tools that patients and family use are God and lawyers," said Nneka Mokwunye, director of the Center for Ethics at the Washington Hospital Center.
"They know that lawyers scare the bejesus out of doctors," she said, "and if the lawyers don't scare them, God will. If somebody says you must keep my loved one alive until God performs a miracle, they don't know how to respond to that."
"WE DON'T DO DEATH VERY WELL"
Recent research into the brain seems to be making it more difficult to say when a terminal patient is actually dead. It turns out that patients considered brain-dead may have a minimal consciousness left and therefore still be technically alive.
"The research seems to suggest that it's very difficult to distinguish the minimally conscious from the permanently unconscious," said Georgetown bioethics professor Robert Veatch.
"There is increasing scepticism that we can really know when someone is permanently unconscious."
Several bioethicists linked efforts to keep terminal patients alive by all means to America's cultural emphasis on staying young and healthy.
"In the U.S., I don't think we do death very well," said Dr Christina Puchalski of George Washington Hospital. "When people are faced with death, there is a big push on survivorship, to help people stay alive as long as they can. I don't think that's bad, but quality of life has to come into play."
Hospitals have been urging people for years to sign advance directives setting out what treatment they do or don't want near the end of life, but only about 15 percent have done so.
"Most Americans don't really believe they're going to die," Lynch said. "This is where so many of the problems start.
(By Tom Heneghan, Reuters)
