O f the various trajectories of physical decline, organ failure is often the most difficult to plan for in advance because of its unpredictability.1 The qualitative study by Davison and Simpson in this week's BMJ challenges the notion that early discussion of planning for the end of life will destroy hope rather than create it. Rather, it allowed patients dying of end stage renal failure and their carers to reflect on and reorient their aspirations.2 A wealth of evidence indicates that many elderly patients want to discuss these issues with their healthcare professionals, but this rarely happens even when (as in the United Kingdom) continuity of care with a trusted general practitioner is available.34 The main barrier is probably doctors' reluctance to raise the issue of planning for death because of the largely unfounded fear of destroying hope. Advance care planning is practised in Australia, Canada, and the United States.5–7 It is also proposed …