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Dr. Jones. You don’t know me and have noreason to trust me, but we have to makesome life-and-death decisions for your husband,and fast.’”The doctors’ difficulty with this simulationspeaks to a larger issue. Althoughsome medical schools now offer basic communicationcourses, training specific to thedeathbed is hit-or-miss. A 1991 study foundthat some schools offered no training in endof-lifesituations at all. New doctors might be alittle better prepared. In 2003, a study reportedthat 60 percent of fourth-year students surveyedhad been trained to discuss treatmentwithdrawal with patients or their families.Yet 82 percent of students and residents saidthey’d taken no courses in end-of-life care. Arecent survey found only about 5 percent ofpracticing oncologists have had anyform of communication training. Alltoo often, doctors are ill prepared forthe needs of dying patients and theirfamilies.Though the details vary, researchshows that dying patients consistentlydescribe the same desires: Theywant to manage their pain and symptoms,feel a sense of preparednessand completion, be valued as a wholeperson, and remain clearheaded andable to make decisions for themselves.Without clear communicationbetween doctor and patient, all of theabove can be difficult.Although Barnato empathizes withher study’s participants, it worries herthat their decisions regarding Smith’streatment have been “all over themap,” from intubation in the ICU allthe way over to what Smith actuallywants: palliative care, a subspecialtyfocused on providing comfort, dignity,and control to patients with lifelimitingillnesses. However, the actorsare trained not to ask for it. “Even in asimplified case in which the simulatedpatient has underlying goals and preferencesthat are scripted and waitingto be unearthed,” says Barnato, “thepatient’s treatment plan is at the whimof the physician.”Barnato says that for the doctorsparticipating in the study, it’s all amatter of perspective. Do they seethe big picture or the immediateproblem—the forest or the trees? Ifthey are focused on the trees, they’relooking at the numbers, adjustingSmith’s oxygen, concentrating ongetting him through the next 24hours. If they see the forest, theyrecognize that there is much more atstake, and now is the time to addresshis wishes directly. The longer thisdiscussion is put off, skirted, orderailed by talk of vitals and treatmentoptions, the less likely it is that Smithwill die the way he wants to.Palliative care began in the United Statesin 1974, when the country’s first hospicewas founded (the Connecticut Hospice).However, it only became formally recognizedas a subspecialty in October 2006. In 2005,the American Heart Association includedpalliative care recommendations in its guide-SUMMER 2007 21