In reply
We agree with Dr Arulkumaran that advanced care planning is essential to provide acutely ill patients will high-quality patient-centered care. A few points of clarification may be helpful.
First, we doubt that our results can be entirely explained by poor decision making. Goals of care were documented in the electronic health record for all patients included in our study, although it is unclear whether this reflects advanced care planning.1 In addition, the association between intensive care unit (ICU) bed availability and changes in goals of patient care was observed for patients with resuscitative goals of care and patients with medical goals of care, a group who clearly has experienced some advanced care planning. Nevertheless, we agree that goals of care should be prospectively defined for all patients and that resource scarcity should not be the factor that initiates clinician-patient discussion of potential therapeutic options. To provide high-quality patient care, we need to ensure that care is consistent with both clinical goals and patients' own goals.2