Much of the recognition of overtreatment stems from countless personal experiences, some documented in print, others conveyed in conversation. In general, the committee concluded that concern about overuse of certain kinds of advanced technologies at the end of life is warranted. Given current cost containment pressures, it will, however, be important to monitor for signs of increasing underuse of such interventions. In addition, it would be useful to understand whether one factor in overtreatment is clinician uncertainty about or unfamiliarity with effective palliative care strategies, including methods of withdrawing mechanical ventilation and other life-sustaining technologies so as to cause minimum distress to patients and families (Brody et al., 1997).

Dimensions of Quality in Care at The End of Life

The literature on quality of care has traditionally distinguished three dimensions for analysis: structure, process, and outcome (Donabedian, 1966, 1980; IOM, 1990). The emphasis in recent years has been increasingly on the outcomes of care, but quality improvement requires an understanding of how structures and processes interact with environmental and patient characteristics to produce outcomes (see, e.g., Chassin et al., 1986; IOM, 1990; Lohr, 1992; Fowler, 1995; Berwick, 1996; Blumenthal, 1996; Brook et al., 1996). Several analyses have recently focused attention on how these concepts can be useful in strategies to measure, monitor, and improve the quality of care for those approaching death (Byock, 1996; Merriman, 1996; Stewart, 1996; Teno, 1996b; AGS, 1997; Donaldson, 1997; Stewart et al., forthcoming).

Table 5.2 depicts the committee's general conceptualization of structure, process, and patient/family outcomes and the larger environmental context as they relate to care at the end of life (see Stewart et al., forthcoming, and Patrick, forthcoming, for alternative conceptualizations). (Economic outcomes, including expenditures for end-of-life care, are discussed in Chapter 5.)

Structures and processes of care are not neatly separable categories, but they can be generally distinguished for purposes of discussion. For analyses intended to identify contributors to good and bad outcomes, the focus is on specific variables (e.g., staffing level or pain management) and their potential for manipulation rather than on their label.

In contrast to structure and process measures, the environmental elements are essentially "givens" rather than variables that can be manipulated by those directly responsible for care at the end of life. Such elements may be particularly important for those with advanced illness. For example, a person who lives alone in a rural area where outpatient or home care resources are scarce may very well face a higher likelihood of institu-



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