Coulehan's perspective on physician-assisted suicide and palliative care emphasizes again the pertinence of communication in end-of-life situations [1]. Coulehan astutely identifies poor communication between physicians and patients as a precipitant of inadequate palliative care, but his comment that failed communication results from a lack of empathy and respect may be misguided and somewhat inflammatory. Although I acknowledge that empathy and respect certainly encourage improved communication with the dying, poor physician communication is more likely to arise from several causes, of which the social background and training of physicians are probably most important [2]. When poor communications skills are coupled with an intimidating confrontation of one's own mortality and the fear of emotional responses from patients and families, incompetent and ineffectual palliative care may occur and, as Coulehan observes, result in a request for "palliation-by-death." As noted by Lynn [3], most physicians' conversations with dying patients are imprecise, inexplicit, and uncomfortable, precluding a meaningful death and a satisfactory bereavement for family members.

To remedy communication difficulties and improve care of the dying, medical schools and training programs must incorporate palliative medicine skills into their curricula, particularly communication techniques germane to end-of-life issues. Unless this is done, care of dying patients will continue to suffer, with frequent physician abandonment of terminally ill patients and continued endorsement of a societal aversion to dying.