AS A LONG TIME end-of-life care executive, I remember well year 1994, when we witnessed willful Oregon voters and their choice to endorse physician-assisted suicide in Death with Dignity Act. Some executives felt that debate that ensued would do a serious disservice to identity and focus of end-of-life care. Others among us - myself included - welcomed chance to open wide topics of preference, expectations, and competence from point of view of patients and families. These issues, coupled with candid concerns regarding abilities of and confidence in provider community, were provocative. Oregon set nation's pace regarding end-of-life care matters. And based on article by Fromme, Guthrie, and Grueber, I feel it's safe to say that Oregon still is a leader. I wonder if knowledge that assisted suicide is a real option in cases where end-of-life care is poorly performed has informed Oregon's excellent palliative care landscape. In many other states - including my own, Illinois - we are not nearly as successful as Oregon is in palliative care and end-of-life care. Certainly, Dr. Weeks and Dr. Nelson suggest in their article that there is more at play than simply specter of suicide driving end of life improvements. Fromme and colleagues' piece cites a magnificent piece by Atul Gawande in August 2010 New Yorker. Dr. Gawande's article is, in my opinion, 2010's best consumer-oriented document on end-of-life care. It references matters of particular concern - letting go, transitions, and timing. These issues play out in different ways in hospital and community. SCIENCE AND COMPASSION BLEND IN PALLIATIVE CARE Our experience at Rainbow Hospice of failed communication, expectation management, truth management, and capability mirrors challenges Fromme and colleagues describe. I can also verify unique utilization patterns described as high care-delivery-intensity regions, such as Chicagoland, in Weeks and Nelson's article. In hospital environment, patients and families are at zenith of fear, isolation, and exhaustion. The worst possible time to discuss end-oflife care preferences and palliative care options is during a hospitalization for an exacerbation (a worsening of illness). Yet it is most common time these matters are raised. Why? A host of reasons: avoidance, confusion, procrastination, denial. Other reasons are more obscure and make navigation even riskier in a hospital environment: health literacy, family pressure, multiple subspecialties, financial worries, socioeconomic privilege, suspicion, doubt. At present, inability to bill a Medicare beneficiary for discussion time on advance directives is a hot topic. While it is sensible that a physician should be paid for consultation time of any sort, it seems not so clear politically. How very unfortunate. I applaud OHSU's deliberate and carefully designed Palliative Medicine and Comfort Care Team, whose work started in mid 1990s, before palliative care was heralded as the next thing by regulatory, accreditation, and funding bodies. Though a substantial number of hospitals say yes when asked if they have a palliative care program, no benchmark exists for determining who should rightfully answer yes. Palliative care programs are defined by some as a part-time nurse who makes rounds to people in pain, or an interventional pain service, or chaplains who navigate anticipatory bereavement. The same question would likely result in significantly fewer affirmatives when measured against this example of a fully articulated palliative care program in a hospital: * A team of palliative care board certified doctors and nurses is deployed as consultants to help manage patients with burdensome, complex illnesses. The focus of work is to enhance quality of patient's experience: use lifetime remaining to help them live every minute as richly as possible rather than die every moment until end. …