Dr. Weinryb is absolutely correct. A competent patient's wishes to refuse life-sustaining treatment should be respected, even if family members object. Because survivors usually benefit so much from coming to peace with their loved one's decision [1], we encourage and facilitate open communication with family members. In "Mr. Larsen's" case, he understood the potential benefit to his family and agreed to the delay needed to reach consensus.

Dr. Baker and colleagues suggest that in New Zealand a hospital ethics committee should approve the disconnection of the ventilator in a case like the one we described. In the United States, competent patients like "Mr. Larsen" have repeatedly been affirmed to have the right to refuse medical treatment. We hold that "Mr. Larsen," not an ethics committee, had final decision-making authority.

"Mr. Larsen's" prognosis for independent function off the ventilator has been overstated by Dr. Oppenheimer. Nonetheless, he is correct in emphasizing the importance of providing detailed information and options to all patients refusing life-sustaining treatment.

We endorse Dr. Buran's appeal for greater sharing of methods to assure patient comfort in the process of ventilator withdrawal. Physicians are often reluctant to do so because of concern over charges that sedation may depress respiratory drive. We concur with the American College of Physicians' position in the third edition of the ethics manual: "ethically and legally there is strong support for gradually increasing the dose of pain medication in terminal illness to levels that relieve pain, even if the side effect is to shorten life" [2].

Mrs. Stewart expresses the fears of many patients and families about a prolonged existence on life support but perhaps misunderstands the sentiments of physicians, many of whom express frustration in their struggle to respect patient wishes to withdraw life-sustaining treatment under restrictive state statutes.

Ms. Wros highlights the vital role of nursing in a patient's terminal care and indeed a nurse ethicist is a member of our hospital ethics consult team. In the case of "Mr. Larsen," the primary nurse was with us at the bedside providing comfort and support to the patient during ventilator withdrawal and to the family after the patient's death.

Dr. Scharf and colleagues make the important point that some physicians find it morally unacceptable to withdraw a ventilator or other life-sustaining treatment from a patient who is not terminally ill. "Mr. Larsen" was not terminally ill, and medical treatment was expected to extend his life for a prolonged period. After being informed of the many options for optimizing his quality of life at home, he refused further life-sustaining treatment. His refusal was based on his own judgment (rather than that of the physicians) of what was an acceptable quality of life for him. Although most physicians respect patients' rights to refuse life-sustaining treatment when they are terminally ill and treatment is futile, some find the withdrawal of a ventilator in a patient like "Mr. Larsen" in conflict with their personal values. The values and moral conscience of these physicians should be respected, but in the process, the patient's right to refuse life-sustaining treatment should not be diminished. Arrangements should be made to transfer the patient's care to another provider who does not find the patient's request to be in violation of their personal or professional values.