I enjoyed reading Dr. Litwin's description of his first encounter with the sudden, unexpected death of a patient during his internship [1]. He describes how, in an early morning meeting with the family of a deceased patient, he finally became a physician. Such encounters capture the essence of our craft; we not only heal the sick but we also guide and give comfort to those who are left behind. We in private practice have the privilege of getting to know patients over decades, which makes such moments even more poignant.

There was also a disturbing side to Dr. Litwin's vignette. The 83-year-old, pleasantly demented nursing home resident had had a previous stroke and was hospitalized for a minor surgical procedure. Dr. Litwin describes the tidy nature of the preoperative data but does not mention whether the patient or family had an advance directive regarding the use of life-sustaining technologies. Indeed, when she had an in-hospital cardiopulmonary arrest, she was "coded".

Fortunately for the patient, she did not survive. Had she done so, she would have been assaulted with a medical armamentarium that would have inflicted pain with little real gain.

Had someone approached the family proactively, the patient may have been spared the "coding". Indeed, her son breathed a sigh of relief when he was told that she just "quietly closed her eyes and drifted peacefully into a sleep". We do our patients and their families an important service by taking the time to discuss such matters proactively.