The essay by Hansot [1] on the intensive care given to her dying, 87-year-old mother was very moving and informative. However, in the context of the trenches of medical practice in communities around the United States, the essay did not address three major issues. In all fairness, Dr. Hansot should deal with these issues if this discussion is to be a source of information and education to physicians.

First, Dr. Hansot neglected to deal with the issue of malpractice. Many malpractice suits have resulted from withdrawing life support, even when legal documents clearly expressed the patient's wishes to have life support discontinued.

Second, Dr. Hansot did not address the unpleasant, but very real, issue of medical insurance. I do not believe that any of the 40 million uninsured Americans would have been subjected to the barrage of multispecialists and multispecialty care that Dr. Hansot's mother was subjected to. This is an unfortunate bottom line consideration for both physicians and hospitals.

The last issue is the very unpleasant and difficult problem of dealing with the same medical facts in a patient half or one quarter the age of Dr. Hansot's mother. What would Dr. Hansot suggest that a physician have done if the patient had been 25 years old with a terminal disease?

I applaud Dr. Hansot's essay and acknowledge her emotional turmoil. However, to deal with this problem in an in-depth medical and ethical manner, one must address the more difficult problems of medical practice. These problems are presented by elderly patients with no realistic hope of an acceptable quality of life.