There are many difficult issues involved in conducting studies that examine the psychological factors of physical illness. One issue raised by Honig is whether the patients in our study who exhibited psychological well-being were those who had opted for extraordinary treatment measures such as ventilatory assistance and, thus, had a longer survival time.While we agree with Honig that many decisions regarding care are the choice of the individual patient, these choices are also substantially influenced by other factors such as the treatment environment, the degree of family support, and the amount of financial resources (eg, type of insurance) of the patient. For instance, the patients followed up at the University of Washington Neuromuscular Speech and Swallowing Clinic (Seattle) are counseled early in the course of their disease about percutaneous gastrostomy and are encouraged to undergo one before their vital capacity falls below 1.5 L. Tracheostomy is discouraged
McDonald ER, Hillel A. Survival in Amyotrophic Lateral Sclerosis-Reply. Arch Neurol. 1995;52(2):126–127. doi:https://doi.org/10.1001/archneur.1995.00540260028009
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