These letters highlight two of the most promising strategies for innovation in end-of-life care. Although mentioned in our discussion, improvements in communication skills and palliative care services deserve special emphasis.

Gertner and colleagues discuss the limitations of advance directives that focus on specific treatment decisions. They encourage physicians to share more information on diagnosis and prognosis and to search out the patient's values and goals for treatment. In this manner, the content of advance planning discussions can move away from the technical details of treatment choices and focus on designing treatment to meet a patient's true needs. We agree with this approach, with the added caution that it requires new and creative training for physicians. In addition, we wonder about the impact of such discussions in a health care system that increasingly disrupts the physician-patient relationship. In contemporary medical practice, the physician who elicits a values history from a capable, ambulatory patient is not likely to be at his or her bedside when death is imminent.

Drs. Adams and Eberle provide a thoughtful discussion of the limitation of palliative care in the hospital, nursing home, and home. Without organizational change, effective communication may not translate into better care for the patient. Writing an order to withhold resuscitation has no impact on the patient's experience of dying. With rare exception [1, 2], the effect of interventions on patient's pain and suffering has simply not been studied. Clinical experience suggests that it cannot be equated with the use or withholding of life-sustaining treatments. Patients and their families may desire reform in other aspects of care even more [3]. Without careful study of the causes and cures of suffering, neither we nor our patients will make good choices about care near the end of life.