A peculiar dynamic in communication exists between those who are most likely to be involved in life-prolongation decisions. We found that both the elderly and health care professionals talk about life-prolongation, but not with one another; that they consider some of the same factors as they think about the life-prolongation decision; and that most of them believe physicians should be responsible for initiating discussion. However, the physician or health care professional who wishes to avoid crisis situations also is reluctant to broach the issue for fear of unnecessarily alarming or compromising the defense mechanisms of the patient. The patient remains patient, waiting--with fears of dependency, memories of previous life-threatening experiences, and deep sensitivity for suffering--for the physician to initiate the discussion. Is a mediator such as a family member necessary in these situations? Is the hospital environment not conductive to discussion of less than heroic efforts?