<i>Editors note:</i>

Editors note: The above letters were referred to the authors of the original paper, and their reply follows. In reply: Our article attempted to show the gap between policy and practice in American nursing homes with respect to attempted cardiopulmonary resuscitation (ACPR). Policy focuses on autonomy and reverence for human life. In practice, the many different burdens of ACPR and the very low likelihood that it will do any good have overcome policy considerations: ACPR is done, as best we can tell, on 3% or fewer of residents who die in nursing homes. In our view this is generally a victory of substance over form. Ferris points out the risk of lawsuit against the facility and its staff. Suing nursing homes is a ubiquitous, expanding, and thriving industry. With these close quarters and terribly ill patients, it is often easy to be damned if you do and damned if you don't. A nurse's decision to refuse to learn CPR is one example of how fear of litigation can affect nursing home residents. A resident who is transferred to hospital to complete the dying process, and thus reduce risk to the nursing home, is another example. Ferris' second point, that high-quality ACPR is often not actually available when it is offered, is complex. We continue to believe that the resources needed to prepare for, administer, and recover from ACPR would be better spent providing goods and services that actually benefit residents in the nursing home. Dr. Kane's two points demonstrate that the battle between form and substance is not over. Suppose there were a nursing home deep in the Yukon River valley, hours away from definitive ACLS. Would it make sense to offer ACPR to all residents? We agree with Dr. Kane that it would not. And yet HCFA, if it has jurisdiction within the Yukon, would insist on individual advance directives. Somehow medical common sense must be reconciled with respect for autonomy. We are not sure what it would take to make HCFA reconsider their position. Deciding whether to attempt CPR in nursing homes is extremely complex. To do so might be mindless overtreatment of a vulnerable dying patient. To fail to do so might be negligent undertreatment of a vulnerable, critically ill patient. Our view is that we should respect the wisdom of the people at the bedside. In nursing homes of all types, with or without religious or academic affiliation, for- and non-profit, regardless of the legal and regulatory climate, caregivers are deciding not to initiate ACPR. This fact should be given great weight in all further policy debate.

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