Approaching Death Improving Care at the End of Life (1997) / Chapter Skim
Currently Skimming:
10 Conclusions and Recommendations
10 Conclusions and Recommendations
Pages 259-271
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From page 259... ...
This is not to claim that dying and death can be made easy, although certain illnesses tend to bring less-difficult deaths than others; nor is it to suggest that caring well for those approaching death can be made an exact science or flawless art. Caring well involves a frequently stressful, imperfect effort to balance science with sentiment, honesty with hope, patterns of care with room for exceptions.
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From page 260... ...
Only a minority of all deaths involve people cared for by formal hospice programs, and the majority of these involve cancer diagnoses. All patients can potentially benefit from good palliative care, but hospice programs as organized and financed in the United States are most applicable to those with relatively predictable prog noses.
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From page 261... ...
The "compression of morbidity hypothesis," for which the evidence is ambiguous, posits that an increase in healthier life styles means that people will experience disabling conditions for a smaller proportion of the years before death than today. Even if this does occur, the overall impact of the larger proportion of older people and their longer life span will still pose enormous challenges for social and health care systems.
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From page 262... ...
Potential problem areas include payment, contracting, and utilization review mechanisms that limit access to clinicians and care teams experienced in palliative care, patient scheduling norms that limit time for careful clinician-patient communication, marketing strategies intended to discourage enrollment or encourage disenroliment by seriously ill people, drug formularies that exclude or restrict important medications, and bureaucratic hurdles that discourage people from seeking care or preclude them from receiving requested services. One characteristic of many managed care organizations is an emphasis on moving more responsibility for diagnosis and patient management to primary care clinicians, including nurse practitioners, nurses, and other nonphysicians.
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From page 263... ...
FINDINGS AND RECOMMENDATIONS Although the committee found many problems, it also found much that was good and improving in care for those approaching death. It was impressed by the principles, aspirations, and practices being advanced by the field of palliative medicine and being implemented or attempted through interdisciplinary care teams in varied settings, including hospices, hospitals, nursing homes, and private homes.
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From page 264... ...
First, too many people suffer needlessly at the end of life both from errors of omission when caregivers fail to provide palliative and supportive care known to be effective and from errors of commission when caregivers do what is known to be ineffective and even harmful. As reported in Chapter 3, studies have repeatedly indicated that a significant proportion of dying patients and patients with advanced disease experience serious pain, despite research identifying a range of effective pharmacological and other options for relieving most pain.
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From page 265... ...
Despite encouraging signs of change, most clinicians-in-training experience and learn too little of the caring that helps people to live well while dying. Undergraduate, graduate, and continuing medical education do not sufficiently prepare health professionals to recognize the final phases of illnesses, construct effective strategies for care, communicate with patients and those close to them, and understand and manage their own emotional reactions to death and dying.
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From page 266... ...
Patient and family expectations and understanding will be aided by advance care planning that considers needs and goals, identifies appropriate surrogate decisionmakers, and avoids narrow preoccupation with written directives. To these ends, health care organizations and other relevant parties should adopt policies regarding information, education, and assistance related to end-of-life decisions and services.
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From page 267... ...
To meet their obligations to their patients, practitioners must hold themselves and their colleagues responsible for using existing knowledge and available interventions to assess, prevent, and relieve physical and emotional distress. Unrelieved pain and other symptoms are the most evident problems that practitioners can readily avoid for the great majority of patients, but problems with communication, appropriate regard for patient and family wishes, and timely referral to palliative care specialists or teams are other areas in need of improvement.
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From page 268... ...
State medical societies, licensing boards, legislative committees, and other groups should cooperate to review state laws, regulations, board practices, and physician attitudes and practices to identify problem areas and then devise revisions in those statutes and regulations that unduly burden clinical management of pain. Regulatory review and revision should be accompanied by educational efforts to increase scientifically and clinically based knowledge and correct misperceptions about the appropriate medical use of opioids and about the biological mechanisms of opioid dependence, addiction, and pain management.
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From page 269... ...
provide expert consultation and role models for colleagues, students, and other members of the health care team; (b) supply educational leadership and resources for scientifically based and practically useful undergraduate, graduate, and continuing medical education; and (c)
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From page 270... ...
To encourage change in the attitudes and understandings of the research establishment, the committee urges the National Institutes of Health and other public agencies to take the lead in organizing a series of workshops, consensus conferences, and agenda-setting projects that focus on what is and is not known about endstage disease and symptom prevention and treatment and that propose an agenda for further research. For the Agency for Health Care Policy and Research, the committee encourages support for the dissemination and replication of proven health care interventions and programs through clinical practice guidelines and other means.
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From page 271... ...
Such widespread changes depend in part on a stronger social consensus on what constitutes appropriate and supportive care for those approaching death. Widely publicized albeit not necessarily typical instances of patient and family powerlessness to stop what they see as futile and painful treatments reflect a lack of such consensus.
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