The episode opens to a voice-over by Izzie Stevens (Katherine Heigl) about how life's biggest moments often come unexpectedly, shaping one's lives in profound ways.

Izzie is excited about the wedding of Meredith Grey (Ellen Pompeo) and Derek Shepherd (Patrick Dempsey), which she prepared and will take place at the end of the day.

Stevens, who has been diagnosed with stage IV metastatic cancer in her brain and liver, has just undergone a surgery to remove a tumor.

Arizona Robbins (Jessica Capshaw) tries to know what went wrong the previous night during her date with Callie but she avoids the subject.

In the meantime, George O'Malley (T. R. Knight) is depressed when all his patients from the car accident die until Hunt tells him one case where he helped has survived.

The episode, written by Shonda Rhimes and directed by Rob Corn,[1] was filmed in Los Angeles in March 2009.

[2] Featured music included Matthew Mayfield's "First In Line", Au Revoir Simone, "Another Likely Story" and Ingrid Michaelson's "Turn To Stone".

[3] Izzie's Amsale dress, constituted of a long tulle skirt with an elaborate crystal-embroidered bodice, was designed by Kenneth Pool.

[6] Rhimes noted that his return, unlike previous ones, were as Death and caused him to wear black clothes and speak sparingly.

[9][10] In terms of viewership, the episode ranked #1 in its time-slot, beating out CBS's CSI: Crime Scene Investigation.

[12] The Los Angeles Times writer Shawna Malcolm wasn't shocked that Izzie and Alex married instead of Meredith and Derek as she had already elaborated that hypothesis weeks prior to the episode's broadcast.

You get us all excited for the long-awaited marital-union between Meredith and Derek, and you pull a great big bait-and-switch with Izzie and Alex.

[15] Todorovich's colleague Ghosh Korbi suspected a week before the episode aired that it would center on Izzie and Alex.

He shared Malcolm's point of view that Izzie/Alex wedding twist was not surprising and concerning other minor plotlines, he called Arizona a "pest".

[4] Meeta Agrawal of Entertainment Weekly said "while Izzie's trip down the aisle was the stuff of fairy-tales, her Amsale gown — with its unflattering drop waist and glitter-pen doodling — didn't quite live up to the fantasy".