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Commentary by Saunders

With this article, the authors contribute to an expanding body of knowledge on end-of-life care in general and to the specific end-of-life issue of communicating end-of-life preferences—certainly, a relevant endeavor. The authors point out the dearth of successful efforts to increase advance directives use. For this study, investigators approached adults in the community who had experience with communicating their end-of-life preferences to their significant others and to their health care providers. The purpose was to describe how they communicated these preferences. The authors developed a semistructured interview schedule from a review of end-of-life research literature and the attuning strategies from communication accommodation theory. They made minor changes in the interview after pilot testing their instrument. Using a descriptive survey design, the investigators recruited a convenience sample of 119 adults from a variety of community settings; the authors did not make clear how they verified that these adults had met the inclusion criterion of having had a previous discussion about their own end-of-life preferences. This research endeavor was rooted in the premise that people who had experienced these discussions might shed some light on how to hold meaningful end-of-life discussions with significant others and with health care providers. Although the findings do shed some light, the issue of how to engage patients, their families, and their health care providers in meaningful discussions remains a largely unsolved challenge. A major challenge with tools (interview schedules or questionnaires) that limit response choices is choosing which items to include or exclude. One of the interview questions for the semistructured interview in this study addressed treatment preferences, and they included the following treatments as choices: cardiopulmonary resuscitation, defibrillation, intubation or tracheostomy and mechanical breathing assistance, dialysis, intravenous fluids, artificial nutrition, antibiotics, preferred setting, and persons you would like present. Absent were any of the following: palliative care, pain management, terminal sedation, or legal measures to hasten death. These items did not appear in the interview schedule and are important omissions in meaningful end-of-life preference discussions.