During my senior year of residency, I brought an elderly gentleman to the operating room with peritonitis and a benign-appearing CT scan only to find a belly full of black, necrotic bowel. We closed him up, told his family, and he died peacefully several hours later. When I presented the case at Mortality and Morbidity conference, one of the attending surgeons asked me why this patient had dead bowel. I ran off a long list of pathophysiologic possibilities, and he replied, "You know, Gretchen, sometimes it’s just a way to die." At the time I thought this was strange, but since then I have come to understand what he meant. Patients often come to the hospital when they are dying. Fear of the unknown and pain typically bring them in, and it’s not uncommon for their primary complaint to manifest as a surgical problem – a gangrenous toe, a dead gallbladder. As surgeons, we often step in and operate right before they die. After a string of poor outcomes, a close friend from