Treatment for Mr. M’s advanced heart failure was no longer extending or improving his life. He was becoming increasingly short of breath and confused -and hospital stays provided only short-term relief. Mr. M’s cardiologist contacted Dr. P, his long-time primary care physician, to initiate a discussion about his goals of care. Dr. P met with Mr. M and his family at their home. Mr. M was adamant that he would rather spend time with his family than go to the hospital again. Dr. P referred Mr. M to hospice and collaborated with hospice nurses to manage his pain and breathlessness. Mr.