Abstract-Background:In retrospective studies, estimates of hastened dying among seriously ill patients range from Ͻ2% in one national survey to as much as 20% in end-stage disease cohorts. Objective: To examine, in prospective studies, dying patients in the months before death, in order to understand the wish to die. Methods: Patients with advanced ALS with a high likelihood of death or need for tracheostomy within 6 months were identified. Patients were assessed monthly with an extensive psychosocial interview, including a diagnostic interview for depression. Family caregivers were interviewed on the same schedule and also after patient deaths. Results: Eighty patients with ALS were enrolled, 63% of eligible patients; 53 died over follow-up. Ten (18.9%) of the 53 expressed the wish to die, and 3 (5.7%) hastened dying. Patients expressing the wish to die did not differ in sociodemographic features, ALS severity, or perceived burden of family caregivers. They were more likely to meet criteria for depression, but differences were smaller when suicidality was excluded from the depression interview. Patients who expressed the wish to die reported less optimism, less comfort in religion, and greater hopelessness. Compared with patients unable to act on the wish to die, patients who hastened dying reported reduction in suffering and increased perception of control over the disease in the final weeks of life. Conclusion: These findings suggest caution in concluding that the desire to hasten dying in end-stage disease is simply a feature of depression.