This article examines the evolution of and need for "end-of-life conversations." Barriers to end-of-life discussions that have been identified in patients and families, health care professionals, and health care systems can seriously interfere with the quality of remaining life for terminally ill patients. Strategies for enhancing end-of-life discussions are most productively linked to (1) physicians' interpersonal communication skills, (2) a patient-centered model of care, (3) a focus on quality of remaining life, and (4) innovative clinical models for implementing these discussions earlier in the care process. We conclude that end-of-life conversations must become a routine, structured intervention in health care and that advance care planning is best viewed as one component in a series of ongoing end-of-life discussions. Randomized trials are needed to examine new approaches and models for enhancing end-of-life conversations. JAMA. 2000;284:1573-1578.