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be developed before transferring patients from ICU to other areas offering lower levels of intensive care" is appropriate. Our article, however, focused on the need to develop criteria that can be applied to presenting patients to evaluate whether or not they would benefit from ICU, or if, in fact they would progress equally well or better in an alternative setting with less intensive levels of care. As was evidenced by our review of the literature, low risk patients are admitted to ICU primarily for observation purposes, and, statistically, they do not require the high levels of care offered by their ICU experience. In this case, they probably would do equally well if admitted to an observation unit that offers the required monitoring of their condition without the high costs associated with an ICU stay. As for your comment regarding "100 percent guarantee of good outcome before chancing a lesser value of care," I don't believe that this is possible or practical in such a situation. What is possible is planning step-down levels of care that offer appropriate backup in the event additional support is required. This approach would offer the patient appropriate levels of security without incurring the high economic costs or elevated risk of iatrogenic illness possibly associated with ICU care. I agree with your observation that the decision to offer maximum levels of care to patients with high risk of death or persistent vegetation state is a decision that the families and society must ultimately make for physicians to feel free to select care based on their best judgements. Until this occurs, physicians will continue to respond to high risk patients with little chance of survival or improved quality of life by giving them the highest level of care available to protect themselves against possible legal retaliation. This may change, however, as the economics of healthcare will ultimately force caregivers to make decisions as to which patients will best respond to a shrinking pool of available healthcare resources. Hopefully, more studies will produce tools that will enable physicians to make more informed decisions about the patients who will benefit the most from intensive care.