In November 2002, the Last Acts coalition issued a report that graded all 50 states and the District of Columbia on eight key elements of end-of-life care. Grades of A, B, C, D, and E (which used to be called F when I was in school) were given to each state’s advance directive and pain management policies, locations of where people die, rates of hospice use, availability of hospital end-of-life care services, utilization of intensive care unit (ICU) care at the end of life, pain reported by nursing home residents, and number of physicians and nurses certified in palliative care (Last Acts, 2002).