End of life decisions are medical, but also ethical and medico-legal issues. Different views on the worth and quality of a human life can cause severe conflicts within medical teams and/or between caregivers and relatives. In these cases, an ethic committee is asked to clarify the patient´s interest. When available, an advance directive is helpful, but may also cause conflicts or confusion. Aim of our study was to describe its value in ethical conflicts about patients suffering from impairment of consciousness. Additionally, the role of legal consultation was analysed.

In our institution, bioethics consultations are held by qualified members of the ethic committee, including physicians, nurses, clerics and lawyers. We examined the protocols of bioethical consultations involving neurosurgical patients. The author focused on the influence of an advance directive on the conflict and necessity of a legal consultation.

12 conflicts involving unconscious or desorientated neurosurgical patients (spontaneous intracranial haemorrhages, traumatic injuries, tumours) were identified. In five cases, a patient´s provision was present. In all these cases, the relatives asked for a termination of life support, what, according to the medical team, was not appropriate at that time.In the conflicts where a directive was missing, there were 4 disputes within the family whether life support should be continued. The last dealt with potential complications of an operation in a patient who was unconscious for seven years. An agreement solving the conflict could be achieved in 5 cases.In half of all cases, the advice of a lawyer was helpful or even necessary

An advance directive is a valuable expression of the patient´s will and autonomy, the highest priciple of bioethics. In our cases, it´s absence caused conflicts within the family. On the other hand, the directive has to be precise enough to avoid differing interpretations. We recommend early and close attention on advance directives in neurosurgical patients.