Approaching Death Improving Care at the End of Life (1997) / Chapter Skim
Currently Skimming:
1 Introduction
1 Introduction
Pages 14-32
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 14... ...
The prevalence of chronic illness and death at an advanced age challenges health care delivery, financing, research, and education systems that were designed primarily for acute illness and injury rather than for serious chronic or progressive degenerative illness. The treatments that clinicians may see as rescuing people, if only briefly, from imminent death may sometimes be experienced by patients and families as a torment from which they need to be freed.
|
From page 15... ...
it Is a dual perversity that interest in assisted suicide sometimes reflects anxiety about overly aggressive medical treatment, sometimes dread about abandonment, and sometimes fear that dying people may suffer simultaneously or sequentially from both misfortunes. As will be described further in this report, the biomedical advances and health care practices that have institutionalized death and sometimes prolonged suffering and dying have not gone without notice or response by nolic~makers.
|
From page 16... ...
The time is right for further action at all levels to improve care for those approaching death and to assure the fearful that they will be neither abandoned nor maltreated. The intense debate over assisted suicide appears to be increasing public recognition of deficits in end-of-life care and consolidating agreement among proponents and opponents alike that people should not view suicide as their best option because they lack effective and compassionate care as they die.1 As discussed further below, a small but growing number of initiatives are beginning to tackle a wide array of health care and other deficiencies that contribute to poor care at the end of life.
|
From page 17... ...
In addition, care for some among the dying may be covered by programs for veterans, military personnel, and homeless people or others who lack public or private insurance. For those approaching death, therefore, government policies play a major role in determining what health care and related services are covered, how health care practitioners and institutions (including health plans)
|
From page 18... ...
If "preventing pain anci other distressing symptoms" is substituted for "preventing illness" in the above description of managed care, then this iclealistic image mirrors in many respects the icleal clescribeci above for the hospice movement anci the fielci of palliative care. Unfortunately, market competition, rapid growth, anci continuing pressure to control costs anci increase profits may encourage practices by some health plans anci organizations that are seriously at ocicis with the icleal image of managed care.
|
From page 19... ...
Hospitals receiving planning grants from the Fund will review care patterns for common fatal illnesses, use focus groups of survivors to assess satisfaction with care, survey hospitals to assess the availability of palliative care services, and convene focus groups of health care professionals to assess their knowledge and attitudes. Follow-up grants for selected hospitals will support the implementation and evaluation of new palliative care strategies.
|
From page 20... ...
The series on care at the end of life will focus on pain management and palliative care, advance care planning, transfers among care settings, and family support. Recognizing the deficits in the knowledge and practice of established physicians in caring for dying patients and those close to them, the American Medical Association has begun a comprehensive, collaborative educational strategy directed at established clinicians (American Medical News, 1997~.
|
From page 21... ...
The target audiences include clinicians of all kinds, professional organizations, health professions educators, state and federal policymakers, managed care executives, public and private purchasers of health care, certifying and accrediting groups, organizations representing patients and families, and the public at large.This document, which was reviewed in accordance with the procedures required by the National Research Council, constitutes the final report of the committee. The nine following chapters examine the way people die when, why, where, and how (Chapter 2~; the elements of good care at the end of life (Chapter 3~; the factors that make it easier or harder to care well for those who are dying including organizational structures and procedures (Chapter 4)
|
From page 22... ...
Individual and system failures to care humanely for dying patients including failures to use existing knowledge to prevent and relieve distress should be viewed as clinical and ethical failures. Care for those approaching death should involve and respect both patients and those close to them.
|
From page 23... ...
Powerful statements about the importance of compassionate care, effective symptom management, advance planning, and similar matters are not enough to improve care of the dying. Making values and policies work organizationally, financially, politically, legally, and otherwise requires a combination of good practical judgment by policymakers and good mechanisms to hold organizations responsible for their perfor mance.
|
From page 24... ...
A bad death, in turn, is characterized by needless suffering, dishonoring of patient or family wishes or values, and a sense among participants or observers that norms of decency have been offended. Bad deaths include those resulting from or accompanied by neglect, violence, or unwanted and senseless medical treatments.
|
From page 25... ...
Such affronts, which even superlative patient care may not always prevent, include pain, incontinence, vomiting, delirium, or traumatic but sometimes appropriate medical interventions. Given this conflict with the everyday meaning of dignity, the concept of a dignified death may unwittingly romanticize death, and its incautious use may produce distress or anger by creating expectations that professional and other caregivers cannot always fulfill for all patients, given the nature of their disease.
|
From page 26... ...
The committee recognized that some people may esteem suffering and even reject efforts to alleviate the physical symptoms that may contribute to suffering. It believes, however, that those caring for dying patients have a responsibility, first, to explain to people that pain and other distress can often be relieved and, second, to consider whether the patient would benefit from an exploration with a chaplain or other counselor of the nature and significance of suffering.
|
From page 27... ...
Likewise, the committee recognized that some people may fear being declared dead prematurely and that trust in those providing care at the end of life may be compromised by controversies about modifying the determination of death to expand the availability of organs for transplantation. Scientists, philosophers, clinicians, theologians, policymakers, and others have sought a scientific, moral, and political consensus on when death can be declared.
|
From page 28... ...
During this period, people may continue many ordinary activities of daily life while coping with the prospect of death and preparing 3As this study was being readied for release, the TOM was exploring a study of ethical, scientific, and clinical issues raised by medical interventions at the end of life that are undertaken to preserve organs for use in organ transplantation.
|
From page 29... ...
INTROD UCTION A Sudden Death from an Unexpected Cause cn cn I Death Time B
|
From page 30... ...
It is also currently important because Medicare coverage for hospice services, which are designed specifically for dying patients, requires a determination that a beneficiary has a terminal illness and, perhaps more intellectually daunting, has a life expectancy of six months or less. Moving from a clinical diagnosis of a terminal or incurable illness expected to end in death to a prognosis a prediction of the course of the illness and remaining life expectancy is an exercise in uncertainty.
|
From page 31... ...
The third and most culturally sweeping meaning of hospice encompasses an approach to care for dying patients based on clinical, social, and metaphysical or spiritual principles. When this report refers to an approach to care rather than to hospice programs or organizations, it generally uses the term palliative care.
|
From page 32... ...
Even the contentious and often bitter debate over the legality or morality of physicianassisted suicide has had positive benefits in forging agreement that deficiencies in care for dying patients may contribute to demands for assisted suicide and that such deficiencies need to be remedied. When he was approaching death, Joseph Cardinal Bernadin reflected, "As you enter the dying process, that process prepares you for death as you slow down....
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.