Shannon, 2001; Truog et al., 2001; IOM, 2003; Curtis, 2004; Tulsky, 2005). Building on the recommendations of previous IOM committees (1997, 2003) and others (Hastings Center, 1987; AACN, 1998), clinical practice guidelines are now available for quality palliative and end-of-life care (National Consensus Project Steering Committee, 2004). Furthermore, progress has been made in integrating end-of-life care into the guidelines, protocols, and standards for critical care professionals (Lo et al., 1999; Shannon, 2001; Truog et al., 2001; Gilmer, 2002; Rushton et al., 2002; IOM, 2003; Curtis, 2004; Tulsky, 2005). Although a gap remains between the guidelines and the systematic integration of those guidelines into clinical practice across the country, progress in integration is being made.

An integrated model would emphasize patient- and family-centered care, interdisciplinary teams, and institutional alignment. Although unintended, one result of the current supply-demand approach is the perception that the goal of the donation request process is to get consent rather than to offer dying patients or their families the opportunity to consider donation as a natural part of dying and death (Australian and New Zealand Intensive Care Society, 1998; Streat and Silvester, 2001; Rocker, 2002; Streat, 2003, 2004; Williams et al., 2003; JCAHO, 2004).

Use of an integrated approach would expand the measures of success of the organ donation process to include whether appropriate donors were identified, whether the family was offered the option of donation (if the deceased person’s wishes were unknown), and whether quality end-of-life care was provided. Other measures would include the quality of the communication about the patient’s dying process and death, the availability of resources for emotional and spiritual support, the management of pain and other symptoms, the offering of end-of-life closure and rituals, and the provision of bereavement services and resources. The assumption, which has not yet been established empirically, is that the provision of excellent end-of-life care would translate into higher rates of organ donation (Williams et al., 2001).

Quality end-of-life care is still a goal rather than a reality for many institutions and organizations. Quality improvement processes and practices need to be implemented in tandem with efforts to enhance organ donation rates. Further, there is still much to be learned about how to develop and follow through on advance care directives. Nationwide efforts have focused more on the designation of healthcare agents who are able to effectively advocate for incapacitated persons. It will be incumbent on OPOs and the transplant community, as they work with hospitals and other healthcare facilities, to improve support for individuals and their families regarding end-of-life care decisions particularly through communications with healthcare professionals, patient and family education about end-of-life decisions and decision-making, and provision of opportunities for or-

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