In reply
We agree with Schneiderman et al that the two studies1,2 in question have substantially different designs making direct comparison difficult. Unfortunately, only limited data relating advance directives to medical costs are available. We appreciate the opportunity to clarify some of the misconceptions regarding our data. Our definition of an advance directive discussion included chart documentation of a discussion between the physician and the patient or the patient's family within the first 48 hours following admission. In practice, most patients do not have an advance directive document with them at the time of admission. Our definition, although imperfect, allows us to include those who had thoughtfully considered the extent of treatment that they desired. In our experience, discussions of advance directives take place when physicians and patients feel comfortable discussing philosophies of care near the end of life. Whether these discussions are conceptualized as physician- or patient-initiated seems