man (1998), an oncologist who teaches communication skills, noted, “Almost invariably, the act of communication is an important part of therapy: occasionally it is the only constituent. It usually requires greater thought and planning than a drug prescription, and unfortunately it is commonly administered in subtherapeutic doses.”

Within the area of communication, teaching how to break bad news has been given the most attention, since it is a common task facing oncologists. An NCCN panel has developed algorithm-based guidelines for delivering bad news, which are being revised for application to end-of-life care (Dr. William Breitbart, personal communication). A review of the literature from 1975 to 1999 (Holland and Almanza, 1999) revealed that of the 166 articles published on this topic, the majority were written in the past five years, reflecting the recent, increased concern about this issue. However, only 14 percent of the studies were based on controlled trials; most papers were based on consensus or clinical experience. Baile and colleagues (1999) proposed guidelines for discussing disease progression and end-of-life care.

Several tenets of importance emerge: finding out what the patient understands; learning how much more or less information does she or he want to know; being sensitive to and empathic with whatever emotions the patient expresses; listening attentively and allowing tears and emotions to be expressed without signs of being rushed; and taking into account the family and its ethnic, cultural and religious roots. All may contribute to decisions about care (Braun et al., 2000; Hastings Center, 1987). These tenets should include attention to the needs of traditionally medically underserved patients: those with little or no English proficiency, for whom care at the end of life is particularly difficult because communication is limited, and patients with chronic mental illness or limited education.

The need for communication guidelines and standards is accentuated because of the awkwardness that many professionals feel in talking with patients about death, as well as the difficulty patients themselves have in expressing their fears and uncertainties about their possible death.

Family members face similar challenges in expressing their feelings and asking questions about prognosis. A series of 19 focus groups held in eight cancer centers comprised either doctors alone, nurses alone, or patients alone. The doctors felt they had more trouble communicating with families than with the patients themselves (Speice et al., 2000). Patients noted that their relatives often felt “left out” and “in the way.” These issues are particularly disturbing since impending death has a profound impact on the family who shares the death vigil with the doctor. Family members often recall in exquisite detail the sensitivity (or lack of it) of the doctor and staff as their relative was dying. These memories affect the grieving process, recalling as they do the details of how the family was told by the doctor about what was being done, how it was informed of changes in the medical



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