Palliative Care in an Out-Patient Radiation Setting????

Just some things that are on my mind these days that I thought I'd share...

I am doing my summer clinicals in an out-patient radiation/oncology clinic. My goal in being there is to become familiar with palliative radiation for intractable bone pain and for symptomatic but incurable brain tumors. I have been surprised, however, how little focus there has been on end-of-life care. Some of the patients are enrolled in hospice and some patients are explicitly receiving radiation for palliative purposes without hope of a cure, but there seems to be generally little discussion of or comfort with death and dying. Prognoses are whispered, "He's not doing well. I'm not sure how much longer he'll make it." But that seems to be the extent of it. I have sat in on discussions of prognoses between patients and their doctors. But despite the low-pressured time the patients get with a nurse, it has surprised me that this subject hasn't come up yet. I am wondering how a radiation/oncology department might incorporate palliative care (beyond physical symptom control and palliative radiation) into its practice.