The methods of the Study to Understand Prognosis and Preferences of Outcomes and Risks of Treatment (SUPPORT), a five year, five-center study of decision making and communication in patients near the end of life, are described. Aspects of the study propose to describe the role of the staff nurse and the specially trained nurse facilitator in decision making in patients near the end of life. The nurse is in a unique position to initiate discussions about patient preferences for end-of-life treatment and quality of life; however, a review of related research describes discordance between clinicians' understanding and patients' preferences for treatment. Ethical issues, practice barriers, and practice innovations in end-of-life treatment are discussed.