The trajectories of functional decline in those diseases that commonly cause end organ failure such as COPD, CHF, and ESLD are similar in that they tend to be longer and more erratic with a constant state of poor and declining health that is interspersed with intermittent exacerbations requiring hospitalization. Death is often relatively sudden and unpredictable, generally arising from complications of the underlying disease. Health care delivery is often reactive rather than proactive and is often initiated in response to acute exacerbations rather than based on a proactive plan of care, which further contributes to poor quality care. Patients with ESLD often pursue curative efforts until the EOL, and palliative care and or hospice is frequently not provided or even suggested until the hope of recovery or transplantation is extinguished, which is often in the last weeks of life.