treatment of psychiatric disorders, we continue to underdiagnose and undertreat the debilitating symptoms of depression, anxiety and delirium in the final stages of life (Breitbart et al., 2000; Carroll et al., 1993; Chochinov and Breitbart, 2000; Hirschfeld et al., 1997; Holland, 1997, 1998, 1999). Also, beyond these physical and psychological symptoms, we fall even shorter of our goals of alleviating the spiritual, psychosocial, and existential suffering of the dying patient and family (Cherny et al., 1994, 1996; Fitchett and Handzo, 1998; Karasu, 2000). Yet the ethical and professional challenge to do so is as important as the obligation to cure (Pellegrino, 2000).

In seeking to provide better care for patients at the end of life, the most effective approach appears to be the use of clinical practice guidelines that establish a benchmark of quality based on the delivery of evidence-based medicine (Chassin, 1998; Field and Lohr, 1990, 1992; Field and Cassel, 1997). This chapter outlines the current status of clinical practice guidelines to guide management of psychiatric, psychosocial, and spiritual distress in the context of managing the physical symptoms at the end of life. The focus is on the management of distress and the interaction of physical symptoms and distress.

Clinical Practice Guidelines in Cancer Care

Public and private agencies in the United States have increasingly focused on the quality of health care being delivered (Emanuel, 1996; Ford et al., 1987; IOM, 1999; Patton and Katterhagen, 1997; Stephenson, 1997). This has been particularly useful in cancer because it has encouraged the scrutiny of care delivered across the disease continuum and the establishment of practice guidelines (Morris, 1996).

Clinical practice guidelines are defined as “systematically developed statements to assist both practitioner and patient decisions about appropriate health care for specific clinical circumstances” (Field and Lohr, 1990, 1992). Guidelines are based on evidence derived from research or clinical trials, or from a consensus of experts when objective evidence is not available. There are two types of guidelines in use. The algorithm or path guideline, the most widely used, directs decisionmaking toward a set standard. The other type is the boundary guideline that defines the appropriate use of a new technology or intervention (often as a cost-saving device). The National Cancer Policy Board (NCPB) noted in Ensuring Quality Cancer Care that the use of systematically developed clinical practice guidelines, based on best available evidence, improved the quality of care delivered (IOM, 1999). Smith and Hillner (1998) reviewed the status of clinical practice guidelines, critical pathways, and care maps and found that care improved with the use of explicit guidelines in 55 of 59 published studies and in 9 of 11 studies that assessed defined outcomes.



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