situation, and especially how attentive the doctor and the staff were in controlling the patient’s distress and physical symptoms (Chochinov et al., 1998; Zisook, 2000).

Communication with Patient and Family: Next Steps
  1. Training of doctors in communication skills is critical to ensure quality end-of-life care. The best teaching model is one that uses faculty from the physician’s own discipline (e.g., oncologists for oncologists) as well as a physician or mental health clinician skilled in teaching communication. Such workshops have proven to have a low priority for voluntary attendance; mandating participation via required risk management lectures is useful. The content of the skills teaching sessions is best acquired when the groups are small in number, when they use videotapes of model patterns of communication, and when they include role playing, which enhances sensitivity to patients’ emotional responses and also to the doctor’s own responses.

  2. Research is needed to determine the best teaching methods. Approaches based on a theoretical model of stress are effective, such as the Transpersonal Model of Stress, which examines physicians’ and patients’ responses at each phase of the discussion (Ptacek and Eberhardt, 1996).

  3. Improving communication with family is recommended, especially in view of the role families now play in physical care at the end of life and the intense psychological impact of this time in their lives and for years to come. We have to explore ways to educate the family in how to manage pain, distress, and other symptoms in the patient and how to communicate with the doctor about their concerns.

Management of Distress in End-of-life Care

A diagnosis of incurable cancer carries with it a necessity for patient and family to look at the meaning they attach to life and death. For many in America, this may be the first unavoidable confrontation with death because, as a society, we prefer to avoid thoughts of death—the last taboo topic. A 1991 Gallup poll found that most people in the United States reported that they never, or almost never, thought about death (Gallup and Newport, 1991). Callahan (1993) observed that much of the public excitement, debate, and furor about physician-assisted suicide and euthanasia is really an attempt to “control death” and thereby avoid facing the actual meaning of death in personal terms.

Given this cultural environment in which the meaning of death is denied and the fact that, in recent decades, oncology research has focused primarily on finding cures as opposed to improving palliative care, it is no



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