The duty to guide patients through the end-of-life decision-making process rests squarely upon primary care providers, writes one internist in The New England Journal of Medicine. Susan Tolle, director of the Center for Ethics in Health Care at the Oregon Health and Science University, is one of three physicians responding to the NEJM's most recent Clinical Decisions" case feature, detailing a woman undergoing treatment for metastatic breast cancer. The two other physicians who responded with their opinions ... claim an oncologist or palliative specialist should initiate the conversation about the patient's goals. But Tolle says it is the primary care physician's obligation to lead this difficult discussion. [Yet] without widespread intervention of primary providers, patients will be less likely to ensure their end of life wishes are honored. Leaders within the American College of Physicians ... agree. "Somebody has to step up," said Robert Centor, Chair of the ACP Board of Regents. "If you're a primary care physician, it's incumbent on you to have the discussion with patients before and especially after they get sick about goals. If we don't know a patient's goals, they can't get the best possible care." End of life planning, however, is not a billable Medicare service.