no standards of care for other common symptoms of cancer such as anxiety, anorexia, or the wasting often associated with cancer.

Communication among various members of the end-of-life care team and with patients may be less than optimal. In one study of terminally ill patients, communication between physicians and patients was poor—only 41 percent of patients in the study reported talking to their physician about prognosis or about their wishes regarding resuscitation (SUPPORT, 1995; Lo, 1995). Physicians infrequently discuss advance directives, and when these are discussed, there is considerable disagreement on the outcome of such discussions. Patients' requests for end-of-life care (e.g., withholding of CPR) are frequently not documented in the medical chart (Haidet et al., 1998; SUPPORT, 1995).

A recent study reports that the vast majority of people with terminal cancer overestimate their chances of surviving their illness (Smith et al., 1998; Weeks et al., 1998). Those who thought they were going to live for six months were more than two times as likely to choose aggressive anticancer therapy instead of palliative or hospice care, which is designed to relieve symptoms. The overoptimistic patients did indeed live longer than those who had more realistic expectations. Patients who overestimated their survival and received aggressive therapy, however, had exactly the same median survival as those who received palliative care and were more likely to have a hospital readmission, undergo attempted resuscitation, or die while receiving ventilatory support. Some patients choose aggressive chemotherapy, even when there is little chance of benefit (Slevin et al., 1990). To achieve the goals of supporting patient values and minimizing the prospect of utilizing therapies that will not increase survival, physicians must make sure that patients understand their prognosis by initiating a dialogue, asking what patients want to know, providing estimates of survival duration, explaining the poor efficacy and debilitating side effects of therapy common at this stage, and discussing all treatment options, including palliative care alone (Smith et al., 1998).

About half of cancer patient deaths involve hospice care. ''Hospice" is a philosophy of care that emphasizes the coordinated delivery of many services for terminally ill patients and their families including: nursing care; physician services; homemakers and home health aides; physical, occupational, and speech therapy; and psychological counseling and social services. Medicare provides a hospice benefit that has criteria for patient admissions and use of therapies. Eligibility for hospice services under Medicare requires an expected survival of less than six months, but most hospice patients live for less than two months following their admission. Physicians appear to delay referring patients for hospice care, in part because it is difficult to predict accurately the expected survival of the terminally ill. Delays in referral may also be due to a physician's lack of knowledge of hospice services, poor communication with the palliative care team, or reluctance to engage in uncomfortable discussions or feelings about end-of-life care (Christakis and Escarce, 1996). Hospice benefits for non-Medicare patients are variable and Medicaid coverage of hospice care varies from state to state.

The National Cancer Policy Board sought additional information about barriers to effective end-of-life care for cancer patients by commissioning interviews with 19 expert physicians, nurses, social workers, and health services researchers. The findings are summarized in the paper, Issues in End of Life Care for People with Cancer: Interviews with Selected Providers and Researchers (Gelband et al., 1999). This approach was taken to complement the 1997 report, Approaching Death: Improving Care at the End of Life, completed by IOM's Committee on Care at the End of Life (IOM, 1997). The 1997 report is a thorough review of end-of-life issues, ending



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