to people approaching death and those caring for them and to develop ways for managers and clinicians to use outcomes measures to improve care in hospices, nursing homes, and other settings (see Appendix E).

Improved end-of-life care has also been identified as a topic for the Breakthrough Series of the Institute for Healthcare Improvement (IHI). This activity uses intensive training and rapid cycles of innovation and evaluation to achieve so-called "breakthrough" improvements in participating programs. Projects have ranged from patient waiting times (e.g., for surgery, emergency treatment, office visits) to cesarean section rates (IHI, 1997). The series on care at the end of life will focus on pain management and palliative care, advance care planning, transfers among care settings, and family support.

Recognizing the deficits in the knowledge and practice of established physicians in caring for dying patients and those close to them, the American Medical Association has begun a comprehensive, collaborative educational strategy directed at established clinicians (American Medical News, 1997). It has solicited participation and information from a broad range of organizations, such as the American Board of Internal Medicine, the American Academy of Hospice and Palliative Medicine, the Picker Institute, the Supportive Care of the Dying Coalition, and many others. A major element of this initiative is a program to train initial groups of physicians who will then return to their communities to teach others. Various other projects are also seeking to redesign undergraduate, graduate, and continuing education in the health professions to help clinicians do better throughout their careers in recognizing, respecting, and meeting the needs of those they cannot cure.

Some organizations, including private foundations are attempting to enlist the mass media in public education about the nature of dying and the ways people can be helped to have a death free from avoidable distress and consistent with their wishes. Journalists, television producers, and others involved in mass communications are also being encouraged to present a less skewed portrayal of death with less emphasis on heroic but implausible resuscitations and violent but impersonal deaths that have few lasting effects on survivors.

A few initiatives are designed to shape Medicare policies related to care of those with serious and eventually fatal illnesses. One, for example, would direct the Health Care Financing Administration to undertake a demonstration and evaluation program in coordinated end-of-life care that would test a range of innovations and focus on capitated models of care (Lynn, 1996b). Others would change how hospice eligibility is determined. In addition, one initiative would require the Secretary of the Department of Health and Human Services to report to Congress annually on the state of affairs regarding care at the end of life.

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