and reduce the frequency of a mechanically supported, painful, and prolonged process of dying. The intervention component of this study included 4,804 patients and their physicians randomized by specialty group to the intervention group (N=2,652) or control group (N=2,152). A specially trained nurse had multiple contacts with the patient, family, physician, and hospital staff to discuss outcomes and preferences, attend to pain control, and facilitate advanced care planning and patient-physician communication. Compared to the control group, patients in the intervention group experienced no improvement in patient-physician communication or in the six targeted outcomes (i.e., incidence or timing of written DNR orders, physicians’ knowledge of their patients’ preferences not to be resuscitated, number of days spent in an intensive care unit [ICU], receiving mechanical ventilation, being comatose before death, level of reported pain). There was no reduction in hospital resources for the intervention. The authors concluded that the type of intervention used to improve communication, education, and advocacy was insufficient to change current practice.

In summary, end-of-life care is inadequate, and much research is needed to improve it. As we have seen, there is also ample evidence of inadequate treatment for the symptoms of cancer. The same reasons for inadequate end-of-life care also apply to the management of pain and other symptoms, including poor assessment, inadequately trained health care providers, low priority for this type of care, lack of patient demand for better care, and negative sanctions against aggressive pain management. As is true of many other medical education efforts, relatively passive continuing medical education programs dealing with these issues have had little effect on practice (Cleeland, 1993; Weissman and Dahl, 1995).

There have been a few studies examining the effectiveness of improving the practice of cancer pain management. A training program that includes the active participation of health care professionals and includes “role models” has demonstrated lasting changes in the cancer pain management knowledge of physicians and nurses (Janjan et al., 1996; Weissman et al., 1993). These studies did not examine patient report of pain as an outcome variable but do suggest that durable change in knowledge is possible.

Beginning with publication of the World Health Organization’s (WHO’s) Cancer Pain Management guidelines in 1986 (WHO, 1986), several guidelines have been issued for cancer pain management, including the Agency for Health Care Policy and Research (AHCPR) Guideline for Cancer Pain Management (Jacox et al., 1994), guidelines from the American Pain Society (1999), and more recently, guidelines from the National Comprehensive Cancer Network. There is, however, only one published study that evaluates the effectiveness of physician adherence to a pain management guideline for cancer pain (DuPen et al., 1999). In this study, 81 cancer patients were enrolled in a prospective, longitudinal, randomized study



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