Critical care physicians are frequently called on to negotiate issues of medical management with patients, their families, and other physicians. These decisions frequently revolve around end-of-life care. Recent data suggest that such discussions are manageable. In one study, 57% of patients and surrogates agreed immediately to a physician's recommendation to limit intensive care and 90% agreed within 5 days, while multiple treating physicians came to consensus about such limits within 4 days in 92% of cases. If conflicts are rare, they are strongly felt. They arise when any one of the parties to a decision insists on continued care against the considered judgment of another. Since the alternative to aggressive ICU care is usually the death of the patient, it seems difficult to reconcile a physician's refusal to treat with patient autonomy. The concept of a fiduciary offers a model of the physician-patient relationship in which the physician commits himself to the patient's best interests but retains a role in defining those interests. This model offers significant benefits over medical futility in negotiating conflicts over end-of-life care.