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Clear, consistent, appropriately timed communication is the cardinal rule in assisting patients and families through the last chapter of life. The physician must not only ensure that his or her communication is appropriate, but also that communication is consistent among the entire team of individuals working with the patient and family. This may sometimes be difficult in an era of multiple consultants and specialists. In addition to what is communicated, the timing and setting are also critical to effective delivery of the messages needed by the patient and family. In “Delivering Bad News,” Bruce Ambuel, PhD, has enumerated several useful factors to be considered when engaging a patient or family regarding important issues:

	Create an appropriate physical setting: A quiet, comfortable room, turn off beeper, check personal appearance, have participants, including yourself, sitting down.
	Determine who should be present. Ask the patient whom they want to participate--clarify relationships to patient. Decide if you want others present (e.g. nurse, consultant, chaplain, social worker) and obtain patient/family permission.
	Think through your goals for the meeting as well as possible goals of the patient.
	Make sure you know basic information about the patient’s disease, prognosis, and treatment options.
	Special circumstances: Patient not competent (developmentally delayed, dementia, etc.) Make sure legal decision-maker is present.
	Special circumstances: Patient doesn’t speak English. Obtain a skilled medical interpreter if the patient or family does not speak English. Use ATT translation service or other phone service is necessary.

Active listening with empathy.

In communication with patients and families, experience is invaluable. Table 2 Dos and Don’ts of EOL Communication should guide physicians as they talk with their patients or family members about end-of-life issues. Of particular importance is the timing of communication. Physicians commonly deliver bad news too late. Patients and patient’s families need time to work through the stages outlined by Elizabeth Kűbler-Ross: denial, anger, fear, bargaining, despondency, and finally acceptance.(1) If the patient’s prognosis is very poor upon admission or immediately following surgery, physicians should immediately inform the family that the likelihood of a good outcome is very low. Information as to the expected indicators of recovery or a worsening condition should be given to family early in the course of the illness, with realistic and accurate updates as the patient progresses, so that family can adjust to the expected poor outcome and expect and accept medical futility when it becomes certain.

The challenge to physicians is ultimately whether or not we are willing to embrace our unique responsibility to our patients, recognizing when all reasonable hope of mastery of disease has vanished, thus providing opportunity for maximal palliative care and a “good death.” We must recognize that timing is everything in the recognition of medical futility: neither before hope for cure has gone, nor after futile treatment has deprived the patient of the best possible last chapter of life. This may be the most important decision we will make for our patients and we must apply all available data and skill to this sometimes difficult decision. It is neither necessary nor wise that we make this decision alone. We should include colleagues, family and others who know the patient well, and spiritual leaders, recognizing and drawing on our own individual spirituality. We must rise above the time-driven pressures and technological temptations of our era to rejoin the priesthood of medicine, serving our patients as their compassionate, loving friends.

^[1] Kubler-Ross E. On Death and Dying. 1997.

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