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I read with great interest the article by Keating et al,1 in which they reported on a national survey about the timing of discussions regarding prognosis, do not resuscitate (DNR) status, and hospice or preferred site of death for terminally ill cancer patients. Their findings indicated that the majority of physicians do not discuss these issues with patients who are feeling well until their condition worsens or there are no more treatments to offer. The authors concluded that more research is needed to understand physicians' reasons for waiting. As a hematologist working in Italy, I experience end-of-life issues on a regular basis and would like to comment.

I am astonished that the patient's opinion is just included in a small discussion at the end of the article, because in my opinion, it is the most important. In fact, I believe the answer is already in the “Discussion” section of the article, namely that patients do not always want to discuss these issues.

Although I understand that national guidelines in the United States recommend advance care planning for terminally ill patients, I completely agree with my colleagues overseas. It is very important to talk to patients and discuss options and prognosis, but not all patients want to know everything and/or discuss it immediately.

Finally, I do not understand whether the DNR issue is something useful in place just to protect “ourselves” from legal action, because I have never had to discuss it with my patients in my 20 years of experience, and I find it inappropriate and extremely insensitive when dealing with a patient who inevitably has no chance of survival.

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