First, you might not reload everything in memory, so it will be patched on disk but not in process.
Second, you have not tested that the system can boot to a functional system. Say you have done live patching for 5 years and never rebooted, and then you have a power loss or hardware failure/upgrade that takes the system down. When you try to bring it back up, it doesn't work. Which configuration change in the past 5 years caused that? Which backup do you use?
And, yeah, everything is hot swappable on VAX. Those machines also cost 6+ figures, and often require a service contract that includes a permanent on site tech.