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	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

To the Editor: In his Grand Rounds, Dr Carrese¹ provides a cogent and practical approach to the problem he terms "refusal of care." However, the accompanying case discussion demonstrates several pitfalls that appear when principles encounter the reality of clinical decision making. The crux of the described case was that the patient's "well-being and her wishes appeared to be in direct conflict." Unfortunately the end result was that neither her well-being nor her wishes were achieved. We see 2 concerns with the case as it developed.

First, the use of the term "patient refusal of care" frames the issue as a dichotomy of options rather than an opportunity for imaginative problem solving. If the only choices presented to a patient are "our recommendations" vs "your refusal," the message she receives may be: "If you want to get out of this hospital, just do it our way." The likelihood of this . . . [Full Text of this Article]

Jeffrey L. Spiess, MD
JSpiess@hospicewr.org

Lisa Tomm, RN
Hospice of the Western Reserve
Cleveland, Ohio

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