I am an internist who sees people with complex illnesses facing surgery. A large part of my job has become talking to people and their families about the risk of death and functional loss after major surgical intervention. We talk about options for treatment, the possibility of death, the role of breathing machines. We talk about the possibility of changing from ‘active care’ to ‘good palliative care’ if the outcomes after surgery look bleak. We talk about doing surgery within a palliative care framework…accepting that the hospital team of doctors, nurses and allied health will so their best to get a good outcome, but if that is not possible, then ensuring we as a team respect the need for dignity and respect if death becomes inevitable. Most importantly we have these conversations in an outpatient setting where there is time to talk about these difficult decisions, and time to come back for a second conversation to answer more questions. I find these conversations personally difficult and draining, but I keep having them. The reasons? My patients are thankful for the opportunity to discuss these issues which have often been worrying them, but they didn’t know how or when to have the conversation, let alone with whom. The feedback from my surgical and intensive care colleagues is also that they are grateful someone has had this conversation with their patients, as they also find these conversations difficult. But perhaps the most important reason is the satisfaction of doing a difficult job well.