We appreciate the responses to our articles. We have received numerous testimonials from people who have had unfortunate experiences similar to Dr. Hansot's. Several of the preceding letters show the enormous difficulty patients and their families sometimes face when trying to have their wishes to limit care respected. Dr. Lena's account of a patient's family and friends having to become personally involved in extubating the patient must be disturbing to any physician. Dr. Ringel asks the key question, How do we prevent such unhappy scenarios in the future?

First, physicians must accept the possibility that patients may not want aggressive care. Dr. Salon argues that the physician's responsibility includes assessing not only the patient's condition but also the patient's wishes. To make such assessments requires time: time to communicate and time to establish a relationship. It also requires that physicians value the physician-patient relationship. Levinson and Roter [1] found that physicians who considered the psychosocial aspects of patient care to be important had better communication skills. Dr. Rousseau asserts that it is essential to teach communication skills to physicians-in-training, and encouraging evidence shows that education can improve communication skills [2, 3].

Dr. Routh argues that living wills are too general to guide decision making in most circumstances. He may be correct. What struck us about Dr. Hansot's and her mother's experience was this: Even though the two of them had discussed what level of care Ms. Hansot would want and even though Ms. Hansot had completed a durable power of attorney for health care that empowered her daughter to make medical decisions for her, the physicians involved still insisted on imposing undesired care. Dr. Harris argues that many patients demand aggressive care despite a hopeless prognosis. Ms. Hansot was not such a patient. Dr. Bohlmann complains that when he and other physicians tried to persuade a patient's family to withdraw care, the family not only refused but accused the physicians of undue pressure. Our point was not that advanced life support is either good or bad. Rather, we were arguing the importance of determining and complying with the patient's wishes. Although we recognize the difficulties presented by critically ill patients whose families request aggressive care even when there is essentially no chance of recovery, physicians must not allow their recommendations to turn into badgering. We find it arrogant for physicians to try to force their recommendations on patients.

We agree with Dr. Glick's point that patients and their families cannot make sound medical decisions without a full and unbiased account of the patient's condition and prognosis. The physician's responsibility is to present such an account and to describe the pros and cons of the therapeutic options. Ultimately, the patient must decide whether to consent to a recommended course of action.

Drs. Reich, Ringel, Harris, and Glick all comment on the subjectivity of medical decisions and the difficulty of accurately predicting the course of many illnesses. Indeed, physicians have an ethical responsibility to be up front with patients about the limited predictive capabilities of western medical science. Although it is clear, however, that physicians and patients alike are forced to make medical decisions with imperfect and incomplete data, this fact does not affect the patient's right to refuse treatment.

Dr. Griffin offers several objections. We did not consult Ms. Hansot's physicians because our purpose in presenting her case was to describe the personal effect of ignoring patients' end-of-life wishes. We believe that cases such as Ms. Hansot's are far from rare and that it is important for physicians to recognize their power not only to heal and to comfort but also to inflict suffering. Regarding legal issues, we stated in our commentary on Dr. Hansot's letter that the law regarding such scenarios is clear. Physicians have no right to impose unwanted care on legally competent patients; Ms. Hansot had a legal right to demand that care be withdrawn. We are troubled by Dr. Griffin's suggestion that Dr. Hansot was somehow to blame for the breakdown in communication. He implies that she should have been better prepared, but how does one prepare for such a scenario? Should we counsel our patients to expect physicians to ignore their wishes and to impose undesired aggressive therapeutic interventions? Should families arrive at the hospital accompanied by a lawyer who could remind the physicians of patient rights? We believe that the physician bears the greater responsibility for establishing communication. In the context of acute critical illness, patients and loved ones are generally distraught, frightened, and overwhelmed. The hospital is not familiar to them in the way that it is to physicians. In cases in which difficulties in communication arise, the physician should identify a facilitator with strong communication skills who can assist. Social workers, clergy, medical ethicists, and psychotherapists are often adept at such a role. Finally, regarding Ms. Hansot's durable power of attorney for health care, Dr. Hansot ensured that her mother's physicians knew that such a document existed. We remain surprised that they showed so little interest in seeing it.