Everyone knows that physicians are chronically evasive and uncommunicative when it comes to death and dying, so how can I argue otherwise?

Yet to view our failures in the care of the terminally ill and dying solely as products of physician attitudes misses, I believe, the larger context in which physicians practice, a context in which clear communication about death and dying is often poorly supported.

Physicians practice in a highly competitive climate in which expectations are often set unrealistically high and the physician who delivers bad news may be seen as negative and defeatist. Our genuine success stories may serve only to intensify the pain and confusion that patients and families face when death happens. For instance, a patient with incurable lung cancer might, thanks to advances in treatment, be given an extra good year. But at the end of that year the physician may be asked: Why couldn't you cure me, or send me to someone who would?

Even in cases in which patients seem to understand that a cure is not possible they often change their minds about treatment. Recently, a patient of mine, an 88-year-old woman with an advanced intestinal cancer expressed the wish not to pursue further treatment and go home to die. The next day, when bleeding recurred, her son called to ask if she could be re-admitted to the hospital. This all-too-human response underscores the difficulties we all face in dealing with death and dying. Who among us can be coolly rational about death? Good physicians do listen to their patients' wishes, yet in the case of death, the difficulties often lie beyond the scope of even the best listener.

While physicians confront death on a regular basis, we are not unlike ordinary people in our general aversion to discuss with patients their impending deaths. There are several reasons for this.

First of all, to discuss death and dying we have to be at peace with ourselves. We have to have accepted our own mortality and have reached some conclusions about our own lives and deaths. We have to have confronted our own potential to die and have made decisions about how we would deal with that.

Secondly, it is difficult to not feel some sense of failure with the death of any patient. Most of us are not good at discussing our failures. To discuss with a patient her anticipated death is to accept that we will be unsuccessful in our attempt to preserve life and to begin to plan for failure.

Often, physicians fail to listen to patients' wishes about dying because it is painful to do so and no physician easily accepts helplessness. Are we so different from those we serve?