It is a sticky June day in Richmond, Virginia, and I am making rounds one last time before I go home for the night. I am a third-year internal medicine resident, closing in on my final day of residency, excited and scared and bitter and tired and READY. I have sent home the interns and medical students and am walking the long, wide halls of the Veterans Affairs hospital. I step into Mr Smith's room and call out, “Good evening, Mr Smith.” There is no response, and, as I turn the corner, I see him lying in bed, staring at the ceiling, eyes wide open. This is not unusual for Mr Smith, who is a nursing home resident with advanced dementia. He was admitted to the hospital for an infectious diarrhea caused by Clostridium difficile, but he does not know this. He also does not know where he is, what day it is, or who I am. He sometimes does not know who he is. There is no family.