Resuscitation orders such as LATOs attempt to bridge the gap between patients' expressed preferences regarding resuscitation and their intended goals. Values-based advance directives highlight this distinction but often fail to provide clinicians with practical guidance on how to act upon their patients' values. In contrast, as pointed out by Dr. Gillick, intervention-specific directives are problematic because they fail to consider patients' goals and often require long lists of clinical scenarios. The LATO is a hybrid that lies between these extremes. By requiring clinicians to explain some of the complexities of resuscitation choices, the LATO clarifies patients' goals and also allows clinicians to determine how these goals should be practically implemented. Moreover, the LATO acknowledges that the effectiveness of resuscitation declines over time (as suggested by Dr. Freer's "short code") and that this information may be of interest to patients.

It is true, as suggested by Dr. LeGrand, that resuscitation may often be overused. This highlights the misalignment of patients' expressed preferences and stated goals, albeit in reverse. We suggested that the LATO may be useful for patients who have existing DNR orders. However, it may also be useful for patients who have requested full resuscitation but may wish to be resuscitated only in certain circumstances.

Ideally, as recommended by Dr. Karnath, comorbid conditions should be considered when attempting to predict the outcome of resuscitation and when discussing resuscitation with patients. Unfortunately, there is an absence of evidence that can be used to make predictions on the basis of individual patient characteristics. Thus, we must use aggregate data (such as the cause of arrest, independent of other factors) to guide our decision making and, in the case of patients with LATOs, should restrict our actions to clear-cut situations. This is particularly true for iatrogenic events, the causes of which are often hard to determine. Overall, we feel that the value of an LATO outweighs its potential problems and suggest that the perfect should not be the enemy of the good.

Dr. Freer commented that it is potentially problematic for a code team to decide when an LATO applies. We agree. Ideally, the conditions in which an LATO applies and the circumstances surrounding an arrest would be apparent. With education and experience, LATOs could become standards of practice, much as the more complex Advanced Cardiac Life Support algorithms used to resuscitate patients have done.