To Drs. Hardin and Loo, we point out that our study did not measure the effect of the advance directive but only the effect of offering the advance directive. We are now studying the possible effect this document has on doctor-patient discussions. Contacts between investigators and patients in the control arm and intervention arm were identical, consisting of periodic interviews to elicit the data described. There was scrupulous attention to avoid influencing patient attitudes and treatment decisions. All patients who asked medical questions were advised to contact their physicians. We are unable to assess the differences in the quantity of discussions about treatment preferences between the two groups.

In response to Dr. von Gunten, we found no evidence of conflict between physicians and patients in treatment decisions, although we agree there may have been times when patients and families "(did) not assert their preferences to such a degree as to cause conflict".

In response to Dr. Grant, we do not wish to imply that treatment discussions should be excluded from the hospital setting simply because they have been previously raised during outpatient encounters. In fact, we state that "only if the document stimulates discussion and communication between patients and physicians will the current enthusiasm for advance directives be justified". As for the application of our findings in the current practice environment, we are concerned that hospitals and other institutions will use the most efficient, not necessarily most effective, way to conform to the Patient Self-Determination Act. In our view, the best use of advance directives would be to help clarify and communicate patients' values and wishes.

We agree with Dr. Sachs that our article should not be used to excuse physicians from discussing important treatment decisions with their patients. Indeed, we had hoped to find additional economic inducement to this communication, following the seemingly reasonable notion that, given the choice, most patients opt for less (and less expensive) aggressive treatments at the end of life. In the reality of contemporary medicine, where multiple providers interact with patients and with a federal mandate, some written document is inevitable. We share the enthusiasm for enhancing physician-patient communication but are much less enthusiastic about the forms presently in use and are trying to improve them.