The essay by Hansot [1] on the obstacles she confronted carrying out her mother's advance directive during a life-ending stay in an intensive care unit is disconcerting and frightening. The blatant disregard for a patient's advance directives, as illustrated in this case, is unjustifiable and intolerable, as are the ignominious communication skills of many attending physicians. Admittedly, there are two sides to every story, but the apparent paucity of basic communication skills exhibited by these physicians has, in my opinion, become more prevalent in this technological era of medical care.

Criticism of communication skills, however, must be tempered by educational realities. Currently, little practical tutelage or experience is available for medical students and residents caring for critically or terminally ill patients, even though communication is consequential to the process of death and dying [2]. Moreover, communication can be arduous and discomforting and can contribute to an onerous physician-patient relationship. This is lamentable because conversation with a dying patient is pivotal to a good death and appropriate familial bereavement. It is regrettable that such difficulty is almost universal. This difficulty originates in three primary precipitants: societal causes, individual patient characteristics, and the social background and professional training of physicians [2].

The latter difficulty is illustrated by the fact that in a recent survey, only 32% of medical residents believed they had received training in informing patients they are dying (Cassel C. Presentation at the American Geriatrics Society Meeting, Chicago, May 1996.). This penury of training will attain greater significance as the United States continues an aging trend that will assuredly draw all physicians close to death and the realm of dying patients. Poor communication may limit the benefits of medical therapeutics and may inadvertently encourage patient abandonment, patient or familial discontent, and litigation. Therefore, it is imperative and obligatory to improve the proficiency of medical trainees' communication skills with patients at the end of life.