• Provide more paid help at home, including in PACE and hospice.

• Require accounting of the aggregate costs and benefits of costly interventions in realistically representative populations.

• Develop a regional or national review process that can limit coverage for particular interventions to particular kinds of patients or can keep a particular treatment from being covered at all.

• Monitor effects of high-cost interventions, especially effects on availability of aide care and psychosocial services.

• Involve HRSA in addressing the concerns of the population needing end-of-life care, including cancer. This would bring to bear the skills and attention of professional educators, manpower experts, health services delivery managers, and innovators and evaluators.

• Tie Medicare payments to quality (e.g., the upcoming effort to tie managed care payments to heart failure performance standards).

• Build culture of quality improvement; pay for the work.

• Consider the role of routine autopsy.

The quality, reliability, and comprehensiveness of end-of-life care are important to cancer patients and their families. Some of the current shortcomings arise from financing and regulations; others, from habit patterns. Enduring reforms must be guided by descriptive and evaluative data, which are not available. This shortcoming should be corrected quickly. We need a decade of vigorous innovation and evaluation, learning how to improve policies. As we settle upon desirable changes, we will also need to forge the political will for reform.

Agra Y, Sacristan A, Gonzalez M, Ferrari M, Portugues A, Calvo MJ. Efficacy of senna versus lactulose in terminal cancer patients treated with opioids. Journal of Pain Symptom Management 1998; 15:1–7.

American Cancer Society. 2000. http://www.cancer.org/statistics/index.html

Beemstrober PM, de Koning HJ, Birnie E, et al. Advanced prostate cancer: course, care and cost complications. Prostate 1999; 40:97–104.

Bennett CL, Matchar D, McCrory D, McLeod DG, Crawford ED, Hillner BE. Cost-effective models for flutamide for prostate carcinoma patients: are they helpful to policy makers? Cancer 1996; 77:1854–1861.

Brooks CH. A comparative analysis of Medicare home care cost savings for the terminally ill. Home Health Care Services Quarterly 1989a; 10:79–96.