In the first bay lay a woman with severe respiratory distress who appeared much older than her actual age of 62 years. She had the look I know too well of someone with multiple chronic medical conditions, so I asked the resident to review the medical chart. “Over 40 pack-year tobacco history, former IVDU on methadone, Hep C, asthma, poorly controlled diabetes, end stage renal disease on hemodialysis, multiple abdominal surgeries and ostomy due to a complicated cholecystectomy.” Her breathing quickened and grew more labored as her oxygen saturation dropped. We barely spoke, but I told her what I planned, yelling above the noise so she could hear me. “We have to put in a breathing tube. Is that okay?” She gave a quick nod. Then I paralyzed and sedated her, performed direct laryngoscopy, and passed the tube between her pearly white cords. I put in a central line, ordered a stat portable chest radiograph, and called the intensive care unit team. I knew that any other emergency medicine attending physician would probably have performed the same procedures and called the same consults, but I wondered if I had done the best for the patient. I have seen this scenario play out too often. While she may survive this hospitalization, her quality of life will be poor and she will suffer. We were managing her from one crisis to the next, without real pause to discuss her wishes or her prognosis.