Mr B and his son were interviewed by the author during a medical grand rounds devoted to discussing palliative care at the University of California, San Francisco’s Moffitt-Long Hospitals. Dr G, Mr B’s primary care physician, was interviewed by a section editor later that month.
MR B: I’ve had a good life. I think when the time comes I’m ready. I don’t want extended medical treatment or a breathing machine. My wife died very young of an incurable brain tumor. She begged people to smother her with a pillow or something. She became gradually worse until finally about the only thing she could move was her eyes. We nursed her along from when she became immobile until she finally passed away. It was a long, drawn-out affair for the children, so I think they’ve had plenty of experience. I wasn’t holding her hand when she died, and I’ve never forgiven myself. Hindsight…If you really knew what was coming. But it’s a mystery, huh? There are always thousands of things that you need to take care of now. Oh, well, everybody does that, don’t they? Don’t they look back and say, “If I’d only…”?
I have a very good doctor. She’s told me herself I can count on her. That made me feel very good. I’ve gotten over the scary part. There are times in your life when you know it’s going to end, and you just have to make up your mind about it ahead of time.
DR G: I stumbled a bit with him at the beginning when he was taking his turn for the worse, not knowing his prognosis…He has pulmonary fibrosis and heart disease, and it’s hard to know…not really knowing what to tell him and not knowing if I’m doing this kind of thing too soon…was hard.
I think about it in relative terms, where he is now compared to when I met him over 3 years ago. He did OK for the first 2 years that I knew him, and then over the next year and a half he really kind of took a turn…now going downhill…a downward sloping course. His quality of life and ability to function are much less. His spirits seem more subdued, and he seems quite impaired by his illness. He never really mentions the word “death” or says “I’m dying,” but he says things in very simple terms, such as “If I get worse, I’m just going to get worse.” He says he’s willing to accept it. Without naming the end point, we’re clearly saying he’s getting sicker. The next step was “Let’s talk about what you would want to do if you got worse, couldn’t breathe, came to the hospital.” He said, “I don’t want anything.” I asked him if he knew what that meant. I explained that if he came in, we would make him comfortable. It might mean fluids and things like that, but we wouldn’t put him on the ventilator or give medications that he didn’t want. He wouldn’t suffer.
It’s hard personally because I really like him. He has an independent spirit…A lot of clinic visits are spent talking about different things he’s doing and thinking about. I’m going to be very sad when he dies. When I think about my practice, I’ll miss seeing him there. That face.
MR B’S SON: Even though he has breathing problems and heart problems, he is at least capable of getting around in his wheelchair. I’d like to see him keep going and do some things, and he would like that. We’re all aware that at some point it’s going to end but want to keep going until it happens.
The Physician and Patient: Facing the Inevitable Together
MR B: Death is a very scary word, but we all have to do it some way or the other. So when we get ready to do it, let’s do it.
DR G: It was always hanging over my head…It was the unacknowledged elephant in the room. Every day I worried that he’d come in with pneumonia by ambulance in the middle of the night, and I wouldn’t hear until the morning that he’d been intubated. I knew I’d feel terrible. I knew this was not what he wanted, so I needed to get it settled.
Patients like Mr B are living longer, partly due to the medical successes of the past 40 years. The intent of medical advances was that health would be maintained a lot longer, morbidity would be compressed, and death would come peacefully.1 Although on average US residents are healthy slightly longer, they spend much more time in dependent states of progressive debility.2,3 Nearly 80% of US residents die in hospitals or long-term care facilities.4 At the time of death, three-quarters are nonambulatory, one-third are incontinent, and 40% are cognitively impaired.5 The end of the dying process is often filled with clinically challenging, ethically complex decisions about withholding or withdrawing potentially life-prolonging treatment.3 Death has frequently become dominated by difficult medical choices, associated with existential, spiritual, and moral confusion, rather than being simply a natural end to the lifecycle.6
With death imminent, patients worry that no one is listening and fear dying with unnecessary pain and suffering.7 The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), a multicenter trial enrolling more than 9000 seriously ill patients conducted in the early 1990s, suggested that these fears may be warranted.8 That study found that 50% of the patients who remained conscious at the end of life experienced moderate to severe pain at least half the time in their final 3 days of life, 46% of DNR orders were written 2 days before death, and only 47% of physicians knew patients’ DNR preferences.8 Of interest, the introduction of a dedicated nurse to encourage awareness of prognosis did not change these outcomes, suggesting that they were largely physician driven.8
Timely, sensitive discussions with seriously ill patients regarding medical, psychosocial, and spiritual needs at the end of life are both an obligation of and privilege for every physician.9 These discussions clarify treatment options and may shift the emphasis from cure to palliation.10 Palliative care focuses primarily on relieving pain and physical symptoms, enhancing psychosocial supports, and assisting patients and families to make the best possible decisions in the face of serious, potentially life-threatening illness.11 Palliative care opportunities should be offered to all seriously ill patients, regardless of their views about continuing disease-directed interventions. Unfortunately, more often than not palliative care is withheld until late in the dying process, if given at all, and is offered as an alternative to usual medical care as opposed to something that can enhance or supplement it.4,12,13 As the extent of suffering progresses out of proportion to prognosis, some patients choose palliation as their primary objective. Such patients should be considered for hospice care, which is the premiere program for providing palliative care to terminally ill patients.14,15 Unfortunately, hospice care is also underused, even for patients dying of advanced cancer.4 The barriers imposed by policy requirements (eg, more likely than not to die within 6 months; necessity to forgo disease-directed treatments) further conspire against hospice selection.16,17 (See also Chapter 8, Palliative Care for Frail Older Adults, Chapter 27, Dignity-Conserving Care—A New Model for Palliative Care, Chapter 36, The Role of Hospice and Other Services, and Chapter 37, Secondary and Tertiary Palliative Care in Hospitals.)
Physicians are also reluctant or unable to tell patients that they are likely to be approaching the end of their lives.18 When physicians do talk about prognosis, they tend to be overly optimistic.19,20 In a systematic review of clinician predictions of survival in 1500 terminally ill cancer patients in 3 countries, Glare and colleagues20 found that in 7 of the 8 evaluable studies clinician predictions of survival significantly exceeded actual survival (in aggregate, median clinician prediction of survival was 42 days; median actual survival was 29 days). Clinician predictions of survival were correlated with actual survival but tended to err on the long side, with accuracy within 1 week for 25% of cases but overestimation by at least 4 weeks in 27% of cases. For the studies in this review, clinician prediction of survival was more strongly correlated with actual survival than other traditional predictors of survival, such as performance status or symptoms, suggesting clinician prediction of survival is still a vital part of prognosticating provided clinicians are aware of their tendency to err on the optimistic side. This reluctance to relay unfavorable prognostic information results both from medicine’s inherent prognostic uncertainty21 and from clinicians’ fears that they will be perceived as “giving up” if they are pessimistic, thereby eliminating hope and depressing patients. However, studies have found that being honest and direct about prognosis does not necessarily eliminate hope or cause depression22-24 and that failure to provide appropriate information about palliative care and prognosis can contribute to unnecessary pain and suffering.8
When Should End-of-Life Discussions Be Initiated?
DR G: We had a series of hospital admissions and many clinic visits for scary episodes—shortness of breath, passing out, falling out of his wheelchair.
MR B: Why do all these stretching out of life measures? It’s not an easy thing, but…it’s inevitable, so you just have to prepare yourself for it.
MR B’S SON: He’s been ill for some time. It seems fairly imminent. I think most of the family is prepared for it. He’s been rushed to emergency on many occasions over the last couple of years. Like my dad says, it’s inevitable, and we’re pretty much fatalistic about it.
Consensus has evolved among clinicians that meaningful end-of-life options are usually offered too late. Fewer physicians agree about which clinical markers signal the time to initiate discussions (Table 1-1).
Table 1-1Clinical Indications for Discussing Palliative Care |Favorite Table|Download (.pdf) Table 1-1 Clinical Indications for Discussing Palliative Care
|Urgent Indications |
| Imminent death |
| Talk about wanting to die |
| Inquiries about hospice or palliative care |
| Recently hospitalized for severe progressive illness |
| Severe suffering and poor prognosis |
|Routine Indications |
| Discussing prognosis |
| Discussing treatment with low probability of success |
| Discussing hopes and fears |
| Physician would not be surprised if the patient died in 6-12 mo |
The following situations suggest urgent indications:
Patients facing imminent death. When death appears imminent, immediate discussion is essential. Frequently, death has been predictably approaching for some time, and discussion already has been delayed too long.13
Patients who talk about wanting to die.25 Sometimes inquiries about assisted dying are really requests to shift from restorative to palliative treatment, particularly if the patient has uncontrolled pain, a family or spiritual crisis, or serious depression.26
Patients or families inquire about hospice. Hospice questions may be a subtext for exploring specific fears about the future or a sign that a patient wants to reconsider the goals of treatment or address unrecognized suffering.
Patients recently hospitalized for severe progressive illness. Hospitalizations, particularly when repeated, suggest that death may be approaching and can prompt a discussion of prognosis and preparing for the end.
Patients suffering out of proportion to prognosis.16 When clinicians feel uncomfortable approaching or treating a patient because of clearly evident suffering, end-of-life issues may have been ignored. Seventy percent of medical residents report that they go against their consciences in treating hospitalized patients overly aggressively while undertreating pain and symptoms.8,27
Routine discussions about palliative care issues may serve all seriously ill patients, even those with a reasonable chance of stabilization or recovery. Normalizing the discussion allows patients to learn about their right to high-quality pain and symptom management28 and educates clinicians about patients’ values and goals. Asking the question “What would be left undone if you were to die sooner rather than later?” gives a message that time may be short.29 The indications for routine discussions might be as follows:
When discussing prognosis. Although frequently avoided or glossed over to “protect” patients and their families,18,19 realistic discussions about prognosis may reassure patients and families wondering what will happen if treatment does not go as hoped.30,31
When discussing treatment options with a low probability of success. Some patients choose to continue therapy with considerable toxicity and poor odds of success simply because they have been presented with no meaningful alternatives that emphasize enhancing quality of life. Of course, a palliative care approach can still be offered alongside even the most aggressive experimental therapies.
When discussing hopes and fears. Most severely ill patients and families hope for the best and imagine the worst. Exploring both sides of this dilemma may be informative for both caregivers and patients.32 Pledging to provide meaningful choices and comprehensive palliative care in the future no matter what the patient’s clinical course can allay many fears.
“Would I (the clinician) be surprised if the patient died within the next 6 to 12 months?”12 Prognosticating when a particular patient will die is inherently inexact. Waiting to discuss end-of-life issues only with those patients highly likely to die restricts the conversation to patients with a few diseases carrying a predictable terminal trajectory.
Mr B met several of the “urgent indications.” He articulated fear of future suffering and talked about wanting to die. His physician felt uncomfortable continuing invasive treatment given his current burden of suffering and poor prognosis, yet initially avoided discussions about future cardiopulmonary resuscitation (CPR). No one involved in his care would be surprised if Mr B were to die within 6 months. As we learned, Mr B’s physician and his family were more reluctant to start the discussions than he was.30
Who Will Initiate and Sustain Discussion About End-of-Life Issues?
DR G: I knew he was ready…and had planned a home visit. The first time we tried, at his daughter’s home, it was really difficult, partly due to the setting. Maybe next time I’ll schedule a separate time to meet privately in clinic to have this conversation and not deal with medical issues.
Because of their long-standing, committed relationship, Dr G was in an ideal position to initiate and sustain discussions about care at the end of life, yet she had difficulty finding a comfortable venue. Some patients, like Mr B, have clearly articulated wishes and values, but even they typically rely on their physicians to initiate the discussion.31 After making a DNR decision together, Dr G was prepared to shepherd Mr B through the many clinical and ethical challenges that characterize the last phase of his life.33
All too frequently, patients and families do not have a long-term relationship with a physician, or if they do, this relationship is threatened, especially when patients change health care settings or programs toward the end of life.4
DR G: [Now] I’ve sort of lost him in the system. He’s going to get placed [in a skilled nursing facility] and be taken away from me. I’m not really involved in his medical care. Nobody calls me about his medications…I worry about what kind of care he’ll get there. Now he doesn’t come see me in clinic. He’s deaf, so I can’t talk to him on the phone…My plan is to go to visit him, but he can’t come see me.
That’s not how I imagined the ending…[I’d hoped] he’d be at home with his kids, and we would be doing this through home hospice…where I could be a big part of it.
Unfortunately, but not atypically, this patient-physician relationship is threatened by Mr B’s admission to a nursing home where medical care is managed primarily by institutionally based physicians. Physicians’ roles are becoming increasingly fragmented over the continuum of care—outpatient care by primary care physicians, inpatient care by hospitalists, and nursing home care by those specializing in long-term care. Physicians like Dr G with long-standing patient relationships are in the ideal position to make palliative care decisions with patients and families.34 Every effort should be made to involve them in major medical decisions across all settings.35
In the absence of such a relationship, a single physician should be designated to coordinate and communicate the medical aspects of each patient’s overall care throughout his/her stay in a given facility, including disease-related and palliative care issues. This physician should encourage full participation by the entire team, including other medical consultants, nurses, social workers, pharmacists, clergy, and family members, as desired by the patient, to maximize the development of a trusting context for subsequent decision making. Patients and families should be able to answer the question, “Who is your main doctor?”
Why Initiate End-of-Life Discussions?
INTERVIEWER: You have this opportunity now to think about, and potentially do, some of the things that you might say are really important.
MR B: Yeah, but you never get them done. I would like to write some poetry, but I just can’t bring myself to start it.
MR B’S SON: We’re a great family of procrastinators. That’s why he’s still here; he’s procrastinating.
Many patients need to know about their clinical conditions and prognoses because their choices differ based on this information. Clinicians are obligated to inquire about patients’ values and wishes and fully inform them of the likelihood of success of aggressive interventions. A case in point is CPR, a harsh procedure usually incompatible with a peaceful death. Discussing DNR is often the first time that patients and families contemplate death and the limitations of aggressive medical measures. Ironically, in the absence of clear information, patients often agonize over CPR, despite abundant evidence that almost no patients with multiple, severe, chronic illnesses who receive CPR survive to discharge.36-38 Patients are less likely to choose CPR once they learn of its lack of efficacy.36,37,39 Beyond addressing CPR, palliative care discussions present the opportunity to address uncomfortable or unrecognized symptoms, such as pain, nausea, and dyspnea, as well as a wide range of other treatments that may or may not be serving the patient’s goals.
Mr B clearly did not want CPR (“Artificial means of keeping me alive—I don’t want any of that. Let me get it over with.”). Had his physician procrastinated or avoided these discussions, the default approach during an unexpected arrest or on presentation to the hospital in extremis would have been full resuscitation, against the patient’s wishes. Apart from medical implications, avoiding end-of-life discussions also may deprive patients of the opportunity to work on issues of life closure.10,40 Tasks such as sharing stories about critical personal experiences, healing family relationships, or completing a will may be left unattended if the patient is unaware that death may be approaching.
What Should Be Included in End-of-Life Discussions?
DR G: [discussing treatment] Should we take a more aggressive approach? Does he need steroids? Does he need immunosuppressants for pulmonary fibrosis? We toyed with that for 2 months…He showed up in clinic, and I said, “What did the pulmonologist say?” and he said, “Oh, I’m not going anymore.” It wasn’t like he and I decided he’d stop going to the chest clinic, and I let them know. It was more that he had already done it. Or “I’ve stopped my prednisone and [azathioprine], I’m not doing them anymore.” And I’d ask, “What’s going on?” and he’d say, “I’m just going to accept what’s happening, and that’s it.” Then he decided that he actually didn’t want any of it. He and I were just going to work together. If this was going downward, we were going to let it.
MR B: It’s going to end up that I can’t breathe…They’ve explained that there’s so much damage to my lungs there’s no way that they can fix them. They’ll just get worse…I’ve gotten over the scary part. I was emphatic about the way I wanted to be treated. And if I got turned loose among a bunch of doctors, who knows what would happen?
A discussion of the relative weight placed by the patient on prolonging life as opposed to enhancing quality of life should usually precede considerations of particular treatment choices (Table 1-2).
Table 1-2What to Include in Most End-of-Life Discussions
Mr B clearly values enhancing his quality of life, avoiding overtreatment, and maintaining personal control, thereby providing a clear context for subsequent discussion about the range of specific interventions.
Although goals should be explored with all seriously ill patients, not every treatment option must be discussed with every patient. Events considered likely to occur given the clinical condition (such as mechanical ventilation for Mr B) must be discussed. In the absence of clear directives, in an emergency, patients receive all available life-prolonging technology. Because Mr B was adamant about not wanting CPR or mechanical ventilation, he needed the medical alert bracelet and home DNR and do-not-intubate orders that resulted from this discussion so that emergency medical technicians would refrain from initiating these interventions. Furthermore, because Mr B did not want to be kept alive if he lost mental capacity to speak for himself, he legally designated one of his children as his health care proxy and clearly stated his desire for “comfort measures only” under these circumstances.
Because Mr B had made numerous emergency department visits for severe shortness of breath, he knew what his future might hold. Yet a decision against intubation and resuscitation must also address management of symptoms, such as acute dyspnea, that are likely to be confronted in an emergency situation. In Mr B’s case, this situation may include a trial of intravenous diuretics and corticosteroids but also the promise of gradually escalating doses of morphine if he continued to struggle with severe dyspnea.38
How Should End-of-Life Discussions Be Broached?
INTERVIEWER: A lot of people worry about doctors talking you into things. Did you want her to try to tell you what she thought about [DNR]?
MR B: Sure.
DR G: When we first talked about it, I talked more in terms of options: “We can be very aggressive or we can do what we’re doing now,” but we didn’t name the third one, which is “We can do even less.” That came next. It sort of came in steps. The first step was deciding not to be aggressive with a lot of medications, hospital admissions, and procedures. That was the first decision, and that was his. I started commenting on how he had started making these decisions and now maybe we should think about what’s going to come up as we go down the road. Let’s start anticipating what’s going to come next. He acted confused, like he didn’t know what I meant. I said that now that we’re not doing the same things we were doing before to try to prevent your lungs from getting worse, and we think they are getting worse, my worry is that you’re going to get sick from that, you could stop breathing. He wasn’t ready to have that conversation, and the setting wasn’t quite right, so I just stopped and was very discouraged by it…Maybe he was hearing me but kind of was saying, “I’m not ready for this. I’ve made 1 step in that direction, but I’m not ready to think about the rest of it.” Then probably a month to 6 weeks later…he could just say it. We were in clinic, and it was just the two of us, and it was a little easier…He was very clear about what he wanted. He seemed to understand everything I would ask. I would say, “Do you understand what I mean?” kind of “Repeat back to me your understanding about what we just decided,” and that part was very smooth.
Although there is no simple formula for initiating end-of-life discussions, Table 1-3 illustrates some representative questions for initiating discussion in a variety of domains. The physician should keep questions straightforward, listen carefully to answers, and then follow the patient’s lead by asking focused follow-up questions incorporating the patient’s language when possible. For example:
Physician: “What has your life been like outside the hospital?”
Patient: “It has been very hard on all of us.”
Physician: “What is the hardest part for you and your family?”
Patient: “My children are very good, but this has turned our family life upside down.”
Physician: “Tell me more about that.”
Table 1-3Representative Questions for Initiating the Discussion About Palliative Care and End-of-Life Issuesa |Favorite Table|Download (.pdf) Table 1-3 Representative Questions for Initiating the Discussion About Palliative Care and End-of-Life Issuesa
|Domain ||Representative Questionsa |
|Goals41 ||Given the severity of your illness, what is most important for you to achieve? |
| ||How do you think about balancing quality of life with length of life in terms of your treatment? |
| ||What are your most important hopes? |
| ||What are your biggest fears? |
|Values42 ||What makes life most worth living for you? |
| ||Would there be any circumstances under which you would find life not worth living? |
| ||What do you consider your quality of life to be like now? |
| ||Have you seen or been with someone who had a particularly good death or particularly difficult death? |
|Advance directives42,43,44 ||If with future progression of your illness you are not able to speak for yourself, who would be best able to represent your views and values (health care proxy)? |
| ||Have you given any thought to what kinds of treatment you would want (and not want) if you become unable to speak for yourself in the future? (living will) |
|Do-not-resuscitate (DNR) order45 ||If you were to die suddenly, that is, you stopped breathing or your heart stopped, we could try to revive you by using cardiopulmonary resuscitation (CPR). Are you familiar with CPR? Have you given thought as to whether you would want it? Given the severity of your illness, CPR would in all likelihood be ineffective. I would recommend that you choose not to have it but that we continue all potentially effective treatments. What do you think? |
|Pain and other symptoms29 ||Tell me about your pain. Can you rate it on a 10-point scale? |
| ||What is your breathing like when you feel at your best? How about when you are having trouble? |
| ||How about other uncomfortable symptoms? Have you had any trouble with eating?…bowels?…confusion? |
|Psychosocial and existential issues10 ||How is your family handling your illness? What are their reactions? |
| ||Has religion been an important part of your life? Are there any spiritual issues you are concerned about at this point? |
| ||If you were to die sooner rather than later, what would be left undone? |
|Hospice16 ||Have you ever heard of hospice? What do you know about it? |
| ||Has your family had any experience with it in the past? |
After fully exploring the concerns of the patient and family, the physician should eventually conduct a “values history” by asking questions such as “What makes life most worth living?” and “What circumstances would make it not worth living?”42 Usually, these general explorations of values, goals, and expectations precede discussions about particular methods of treatment.
DR G: I was worried that [our DNR discussion] would get back to his kids. I felt in some ways I was buffering him a little bit from his kids. I wasn’t sure how they were going to react. I said, ”You need to talk about this with Becky who is your [durable power of attorney for health care] because you’ve now made a decision that you’ve told me about so it’s sort of official. You need to make sure that she knows that that’s what you’ve decided.”
MR B’S SON: I’d like him to hang around for a while because I enjoy him very much. I would hate to lose the guy.
Mr B clearly has full capacity to be the central decision maker for his life, yet his family is very invested in his continued longevity. The physician must ultimately guide the discussion to the most critical medical aspects of the decision46 but can also serve as the patient’s mediator and advocate with the family.43,47,48 In these discussions, a keen awareness of the patient’s cultural, ethnic, and religious background is critical because these contextual issues may profoundly influence decisions.49,50 (“I was baptized a Catholic, but I never followed up on it. I think that when a person reaches a certain point, if they want to die, they should…I don’t think a superior being is telling us how we have to go.”)
Throughout the late stages of disease, physicians are frequently called on to address difficult questions (Table 1-4). Existential and spiritual questions may not be answerable, but all questions call for an honest and compassionate exploration of the patient’s views and experiences.7,29 Questions about prognosis may be answered as a range of periods (eg, “minutes to hours,” “days to weeks,” or “months to years”) while always acknowledging the possibility of exceptions in either direction and the potential frustration of not being able to prognosticate more precisely.51 Physicians should not shy away from making recommendations or providing guidance, particularly when requested by the patient or family.46 With her intimate knowledge of his medical condition and his personal wishes, Mr B’s physician recommended completing a DNR document and also avoiding mechanical ventilation. Although making this recommendation caused her anxiety, withholding her experience and guidance would have been inhumane.
Table 1-4Some Difficult Questions From Patients |Favorite Table|Download (.pdf) Table 1-4 Some Difficult Questions From Patients
|Why me? |
|Why didn’t you catch this earlier? Did you make a mistake? |
|How long do I have? |
|What would you do in my shoes? |
|Should I try long-shot or experimental therapy? |
|Should I go to a “medical mecca” for treatment or a second opinion? |
|If my suffering gets really bad, will you help me die? |
|Will you work with me all the way through to my death, no matter what? |
DR G: Talking about it with him was very hard because I knew him very, very well…and was so invested in him…It was more complicated because I wasn’t a neutral person. I had my opinion about what his code status should be and how much treatment he should have. I hoped I was giving him good advice…That was my worry afterwards. Then I thought, “You know what, you’ve been thinking about this for a long time, and this is right.”…I remember saying something like “If it helps, I agree with your decision.” I was thinking it might help him to know somebody was with him. He taught me a lot. I draw upon him, the experience, a lot. It feels good to talk about him in that way.
Dr G struggled with her feelings but ultimately chose to share her views about resuscitation with Mr B. This was both a statement of solidarity with Mr B and a willingness to help him make the best decision possible. Because she cared deeply about Mr B, what happened to him in the last phase of life mattered to her personally.34 Engaging in intimate, end-of-life decision making with patients and families can be both emotionally enriching and psychologically draining.52 Physicians should share uncertainties about treatment options and solicit input from other members of the health care team. Equally critical for clinicians involved in end-of-life care is the opportunity to discuss personal reactions and receive support in a safe place.53
Helping patients achieve as good and meaningful a death as possible is part of what we do as physicians. When physicians provide their patients with the honesty, expertise, advocacy, compassion, and commitment they would want for themselves and their families, they provide the highest quality of medical care possible. For some patients, the approach will include an improbable fight for life at the cost of considerable iatrogenic suffering. For others, the primary goal will be more to enhance quality than prolong the length of life. Some, like Mr B, will be open and articulate about their end-of-life wishes and values, whereas others may not want much open discussion. Allowing for these differences, patients must receive excellent pain and symptom management, clear information and guidance about their disease-related and palliative care treatment options, psychosocial support, and, if desired, an opportunity to work on life closure. There is little or nothing to lose in initiating palliative care discussions earlier and more systematically in a patient’s final trajectory, and so much is lost when these discussions are avoided.