The current standard is to give care only to those who can benefit from it, said Dr. E. Louis Priem, Mt Sinai Medical Center's chairman of medical ethics. A few years ago in the New England Journal of Medicine, people were asked if they would give CPR to a Leukemia patient with no hope. For many people, the guideline there would be personal choice. But in cases where an advance directive has been issued and the family disagrees, few hospitals will push the issue. Extreme cases of disagreement can be taken to the hospital ethics committee, which is rare, Priem said.
Most resolutions are a matter of negotiation.
You take the family through steps. In the emergency room even if someone probably won't be getting well, you really want to stress to the family what you are doing with the patient and what you will do to further evaluate the situation. Once a patient is in ICU and the situation is clear, you talk to the family about what to expect. You tell them that probably they'll see that the person won't be able to move, won't be able to communicate or know the family is there. If you are true to your word, they'll learn to trust you and see that you're right.