When medical interventions were few, "doing everything" was rarely questioned. But new technologies have patients and medical professionals asking if "everything" promotes patient well-being. Medical, legal, and ethical consensus provides that competent adults may refuse treatment, and that appropriately withholding and withdrawing therapy constitutes neither homicide nor suicide. Although no ethical distinction exists between withholding and withdrawing, powerful symbolic and emotional differences may create ethical confusion.

Defining and clearly communicating goals of care remain critical to deliberation. In order to make informed choices, patients should understand the ultimate purpose of recommended treatment. Team members must comprehend treatment goals in order to recommend appropriate care (palliation, for example, rather than cure).

When genuine uncertainty exists about treatment benefit, we should err on the side of preserving life. However, it does not follow that once begun, treatment can never be withdrawn. Treatment trials should be initiated, the patient closely monitored, and benefit assessed at appropriate intervals. Implementation of treatment trials provides reassurance that physiologic data will not overshadow patient well-being.

No treatment is intrinsically "ordinary" or "extraordinary," and using such terms may confuse. "Ordinary" therapy in one setting be "extraordinary" in another. Medical staff often use "heroic measures" to mean "low likelihood of success," but lay people frequently equate "heroic" with "lifesaving."

Rather than using vague expressions (including "doing everything," or "doing nothing"), each therapy's purpose should be discussed relative to the patient's condition. Treatment effects must be distinguished from benefits, since therapy producing physiological effects may not improve the patient's prognosis.

Determining whether treatment burdens are proportionate to benefits must include the patient perspective. "Routine" therapy only minimally painful or intrusive may be disproportionate to benefits if the prognosis is poor and therapy impedes other patient goals.

When it is clear that therapy is not beneficial, withdrawal is ethically permissible. However, the machinery of medicine—such as heart monitors and ventilators—provides visual symbols of "caring." When removed, the unspoken feeling may be that "Nothing is being done." Aggressive palliation, informing family about symptom management, and including them in appropriate aspects of care, can overcome unintended messages.