In Reply Dr Alfandre and colleagues call attention to the clear and forward-thinking policies relating to surrogate decision makers in the VHA. We chose to use data from the VHA in our study because this database contains detailed information, which is not available for other large populations, about the relationships between patients and their next of kin.

These data provided a unique opportunity to explore a phenomenon that is also likely to be found among patients in health systems whose policies for identifying surrogates are less explicit and uniform and are governed by state default surrogate statutes, which contain a variety of decision making hierarchies.