Drs. Sandler and McDonald advise a lapse of several days before implementing a decision to withdraw a patient's ventilator. We agree that the carefully considered, well-planned withdrawal of life-sustaining treatment is less emotionally demanding for providers. We believe that for most patients it is better to administer gradual sedation with a morphine drip rather than to give bolus doses of medication. However, at times these procedures do not meet the patient's wishes, needs, or values. For some patients, several more days of life-sustaining treatment represents an intolerable burden. In setting time lines for ventilator withdrawal, we must not lose sight of the unique needs of each patient and family.

Dr. Hooyman raises concerns about our dual roles in "Mr. Larson's" care. We concur that, in general, ethicists should advise the health care team and not play an active role in any form of treatment withdrawal. Because of our dual qualifications as ethicists and physicians, we assumed the attending role in this unusual case in a time of need.

We are troubled by Dr. Hansen-Flaschen's description of the patient who suffered for 3 weeks with inadequate medication to relieve her dyspnea. We are deeply concerned that inadequate symptom control in terminal illness is all too common. While providers grapple with their fears of shortening life, too many patients, like this woman, are suffering.