to the editor: We commend the authors of this article for their comprehensive review of palliative pharmacologic interventions to relieve distressing symptoms as patients reach the end of their life. It was heartening that the authors advocated for hospice support for the patient and his or her family, as well as an understanding that a patient's preferences and goals should direct the care.

There is sometimes a gradual shift in interventions as a patient moves from curative treatments to palliative care. However, there is little or no training in how to recognize when a patient has begun the dying process. There is rarely a clear demarcation between the stages of living with and dying from a chronic disease. When entering the dying process during the last three to six months of their life, all patients act the same regardless of what organ system is failing. They go from eating, to tasting, to just looking at food. There is often a reversal of the sleep-wake cycle. There is a decline in functional ability, with the patient needing more assistance with activities of daily living and instrumental activities of daily living. There is also an increase in caregiver stress.

We identified a knowledge deficit in our medical community and created a booklet and presentation to help doctors recognize the indicators that identify a dying patient. These indicators and other useful tools are available on the Hospice of Marion County's Web site: http://www.hospiceofmarion.com/physicians.html.