We appreciate the comments of Dr Dahlerus et al about our Editorial describing opportunities and risks created by the proposed quality measure, the ESRD Dialysis Patient Life Goals Survey (D-PaLS), which she and her group developed.1 To the first point raised, that the D-PaLS was not designed to evaluate the worth of individual life goals, we maintain that some patients may nevertheless interpret the survey questions as value judgments about their goals. We want to acknowledge the deeply thoughtful and rigorous work that went into developing this measure, which is excellent, while also reaffirming the role for caution when asking patients to share personal goals within a health care system that has not always earned their trust.