The discourse analysis of end-of-life discussions presented here describes the interplay between the institutional order and interactional order in American medicine following Sarangi and Roberts (1999). In American hospitals, the institutional order of end-of-life discussions is accountable to a bioethics model of patient/surrogate autonomy for making medical decisions. In end-of-life care, medical futility is the basis for the decision to withdraw life support from a terminal patient; under autonomy in a bioethics model, this decision should be made primarily by the patient’s surrogate in consultation with the attending physician. The interactional order of discussions with patients’ families, however, is largely without accountability to institutional policies mandating autonomy, instead following the clinical and ethical standards of the profession of medicine, which preserve the determination of medical futility as a professional judgment and limit the scope of surrogate autonomy to an account of the patient’s wishes. In these discussions, physicians and families can be seen as constructing an ethics of emerging consensus as the basis for end-of-life decision-making.