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Family members are involved in every aspect of end-of-life decision making and care. The present article reviews family involvement in providing care during chronic and terminal illness, in discussions and plans for advance directives, in decision making during chronic illness, in executing advance directives and making critical decisions near the end of life, and the long-lasting effects of caregiving and difficult decisions on the family member during bereavement. Although legal standards and much of the research on end of life emphasize individual decision making and the value of autonomy, end-of-life care and decisions should be increasingly understood within a family context. There is also increasing need to study how issues of race, ethnicity, and culture affect end-of-life care and decisions within families.

As a society we have recognize that an individual should have the right to provide informed consent regarding his or her care. This right extends to end of life decisions as long as they do not contradict current legal mandates (for example assisted suicide). Virtually all 50 states have passed legislation which allows patients to refuse life support and at the Federal level the Patient Self-Determination Act (1990) promotes this right at least within an Health Maintenance Organization environment.

Research suggests that communication near the end of life is problematic. A literature review was conducted to identify barriers to optimal communication near the end of life and strategies to overcome them. Barriers include clinician beliefs, patient characteristics, American popular and medical cultures, and the health care system. Clinician and patient barriers can be addressed through education, advance planning, the inclusion of patients' family members, and individualizing care. Cultural and systems problems can be addressed through public as well as professional education, alternative models of care, and coalition building. Combined, these approaches can help improve communication near the end of life and ultimately improve care for the dying.

End-of-life public policy has the potential to affect everyone. The purpose of this article is to provide an overview of recent significant policy activity. The authors begin by reviewing the Medicare and Medicaid hospice benefit and the Patient Self-Determination Act, highlighting state-level developments, and noting significant court cases. They then discuss common concerns with Medicare, advance directives, hospice, and pain management and provide proposed remedies for the concerns. The article ends with recommendations for advocacy by behavioral and social science professionals.