Approaching Death Improving Care at the End of Life (1997) / Chapter Skim
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Summary
Pages 1-13
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From page 1... ...
System changes not just changes in individual beliefs and actions are necessary. A number of developments suggest that the time is right for action at all levels to improve care at the end of life and to assure people that they will be neither abandoned nor maltreated as they approach death.
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The dying process today tends to be more extended, in part because medical treatments can manage pneumonia, infections, kidney failure, and other immediate causes of death that come in the wake of cancer and other "slow killers." The field of palliative care is one response to the changing profile of death in the twentieth century. It focuses on the prevention and relief of suffering through the meticulous management of symptoms from the early through the final stages of an illness; it attends closely to the emotional, spiritual, and practical needs of patients and those close to them.
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Possible problem areas include contracting, payment, and review mechanisms that limit access to clinicians and care teams experienced in palliative care; patient scheduling norms that limit time for careful patient-clinician communication; and marketing strategies that may discourage enrollment by seriously ill people.
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Good care at the end of life depends on strong interpersonal skills, clinical knowledge, and technical proficiency, and it is informed by scientific evidence, values, and personal and professional experience. Clinical excellence is important because the frail condition of dying patients leaves little margin to rectify errors.
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From page 5... ...
fitting palliative and other care to these goals. In looking at current systems and practices, the committee found much that was good, including clinics i, organizational, and ethical practices of palliative medicine that are implemented through hospices, interdisciplinary care teams in varied settings, innovative educational programs, and nascent outcomes measurement and quality monitoring and .
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Many deficiencies in practice stem from fundamental prior failures in professional education. Undergraduate, graduate, and continuing education do not sufficiently prepare health professionals to recognize the final phases of illnesses, understand and manage their own emotional reactions to death and dying, construct effective strategies for care, and communicate sensitively with patients and those close to them.
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From page 7... ...
They should learn before their last few days of life that supportive services are available from hospices and elsewhere in the community and that those involved in their care will help arrange such services. 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.
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From page 8... ...
reform drug prescription laws, burdensome regulations, and state medical board policies and practices that impede effective use of opioids to relieve pain and suffering. Although individuals must act to improve care at the end of life, systems of care must be changed to support such action.
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From page 9... ...
"Whole-community" approaches to end-of-life care would include a mix of programs, settings, personnel, procedures, and practices that extend beyond health care institutions and policies to involve entire communities. The goals would be to make effective palliative care available wherever and whenever the dying patient is cared for; help dying patients and their families to plan ahead and prepare for dying and death; and establish accountability for high quality care at the end of life.
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From page 12... ...
Demonstration projects to test new methods of financing and organizing care should be a priority for the Health Care Financing Administration. 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 13... ...
These reasons range from the examples of well-known men and women facing death with grace to the more intense focus on deficiencies in care that has been stimulated by the debate over assisted suicide. In sum, the timing appears right to press for a vigorous societal commitment to improve care at the end of life.
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