Technologic and organizational advances in health care have created an ever-growing population of survivors who depend upon mechanical aids for breathing for their quality of life—or even survival itself. Among these are an increasing number of the 7,000 to 8,000 new survivors of traumatic spinal cord injuries each year whose injury results in quadriplegia (53 percent). Those with high lesions (C-l to C-4) become dependent on a ventilator because of chronic respiratory insufficiency or failure. Many such survivors must inappropriately remain in acute intensive care centers at enormous cost, economically and in human terms. With continuing progress and success of emergency medicine, critical care, and comprehensive rehabilitation, the issue of “what to do next” has grown to a crisis for national and international attention.