to the editor: I read with great interest the article "Making Decisions with Families at the End of Life,"¹ by Drs. Lang and Quill. I am a faculty physician responsible for teaching residents and students, and end-of-life issues often arise, especially on the wards. I agree with the approach used by the authors1 to address this issue, but I would add two other points. In the article’s section entitled "Communication Pitfalls," the authors suggest another way of forming a question about end-of-life issues (i.e., obtaining a “do not resuscitate” [DNR] order or continuing total care) by asking: "Do you want to have everything done for comfort or everything done for survival?" I agree that, to some patients and their families, “do not resuscitate” translates as “do nothing” and has a negative connotation. For residents and attending physicians, especially those who admit unassigned patients to the hospital and who have not had the opportunity to develop a rapport with the patient or family, bringing up the subject of end-of-life issues can be seen very negatively in the eyes of the patient or the patient’s family. I would suggest that revising the wording be taken further regarding the question or statements concerning DNR orders. I suggest we use the term "allow natural death." Also, as is done in some institutions, after the question "Do you want everything done for comfort?," ask "Do you want everything done for comfort and to allow natural death?"

My second point is that this article1 demonstrates that physicians must do a better job of addressing this issue before hospitalization, when possible. Before you can address end-of-life issues with patients or their families, you must be comfortable having this discussion.² How to initiate and complete this discussion seldom is emphasized during physician training. We must become better at teaching this skill during medical school and residency when we, as educators, have the greatest impact on our younger physicians.