WEST PALM BEACH, Fla. (AP) — An Institute of Medicine report says Americans often suffer needless discomfort and undergo unwanted and costly care as they die.

The “Dying in America” study released Wednesday was done by a panel of 21 experts. It finds that people repeatedly stress a desire to die at home, free from pain, but often the opposite happens.

The authors blame a medical system ruled by “perverse incentives” for aggressive care, inadequate physician training and too few conversations about end-of-life wishes.

They say patients’ advance directives have not been particularly effective, and urge a series of conversations throughout life about what’s desired in death. They say those talks should begin early, perhaps when people are teenagers.