It works well though. In the end it's not so much the plot twist that matters, as the significance of the allegory that the film presented. Also, each scene has a significance, every character a role, and the way realiy, memories and hallucination are meshed together is clever and eye-opening.
If the entire story only relied on the plot twist to grab my attention at the last minute, then we'd have another The 6th Sense, and I'd probably have fallen asleep. Luckily, that wasn't the case, and I witnessed a truly great and profound film.
You're right - the "he's dead/dying and doesn't know it" plot twist is hardly the centerpiece of the film. I caught onto this fairly early on into the film, but it never ruined my appreciation for the movie. Everything you say made the film great would still be there even if we knew from the get-go that Jacob was dying on a gurney.
Case in point: in the movie
Johnny Got His Gun, we know that everything we're seeing is the protagonist's memory, dream, or fantasy. That's probably a closer comparison to
Jacob's Ladder than
The Sixth Sense (and about a dozen other films of that type), where the alleged plot twist is the entire substance of the film.
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