Numerous articles, such as Dr. Hansot's essay [1] and the accompanying article by Gilligan and Raffin [2], imply that there is almost an epidemic of helpless patients being kept alive in agony by heartless, mechanistic physicians. I am perplexed, however, because my own experiences tell me otherwise.

For every patient, or patient's family, who requests withdrawal of life support, I encounter 10 who do the opposite, who adamantly insist that "everything be done," even when I and other physicians advise that such measures are futile and serve only to increase and prolong suffering.

When a patient or the family does request termination of life support, I simply do not see (and hopefully do not manifest) the insensitivity that Dr. Hansot experienced. But I practice in private hospitals in a relatively small community. This leads me to wonder whether the remote, unfeeling, "scientific" physician is mainly a phenomenon of academic medical centers, where these two articles seem to have originated.

I would further emphasize that the situation is rarely as clear-cut as that of Dr. Hansot's 87-year-old mother. Typically, the patient is not this elderly; the prognosis is not this certain; and the patient and family are not this informed, decisive, and articulate. Patients' decisions, no matter how firmly stated, are often not final. In my own specialty, many patients with advancing renal failure will make it quite clear that they wish to die rather than go on dialysis-giving very plausible reasons for their decision-and then change their minds at the last minute. This is so common, in fact, that I usually make plans for dialysis despite a patient's "decision" to decline it; I do not believe this reflects physician arrogance but rather my experience with how patients deal with a new and very threatening situation.