RECOMMENDATION 2: Physicians, nurses, social workers, and other health professionals must commit themselves to improving care for dying patients and to using existing knowledge effectively to prevent and relieve pain and other symptoms. Most patients depend on health care professionals to prevent and manage the varying physical and psychological symptoms that accompany advanced illness. To meet their obligations to their patients, practitioners must hold themselves and their colleagues responsible for using existing knowledge and available interventions to assess, prevent, and relieve physical and emotional distress. Unrelieved pain and other symptoms are the most evident problems that practitioners can readily avoid for the great majority of patients, but problems with communication, appropriate regard for patient and family wishes, and timely referral to palliative care specialists or teams are other areas in need of improvement. When good practice is hindered by organizational, financial, or legal impediments, health professionals have the responsibility as individuals and members of larger groups to advocate for system change.

RECOMMENDATION 3: Because many deficiencies in care reflect system problems, policymakers, consumer groups, and purchasers of health care should work with health care providers and researchers to

  • a.  

    strengthen methods for measuring the quality of life and other outcomes of care for dying patients and those close to them;

  • b.  

    develop better tools and strategies for improving the quality of care and holding health care organizations accountable for care at the end of life;

  • c.  

    revise mechanisms for financing care so that they encourage rather than impede good end-of-life care and sustain rather than frustrate coordinated systems of excellent care; and

  • d.  

    reform drug prescription laws, burdensome regulations, and state medical board policies and practices that impede effective use of opioids to relieve pain and suffering.

Although individuals must act to improve care at the end of life, systems of care must be changed to support such action. System change requires the involvement of public and private purchasers of care, regulators, and others whose policies and practices may create incentives for inappropriate care and barriers to excellent care.

Better information systems and tools for measuring outcomes and evaluating care are critical to the creation of effective and accountable systems of care and to the effective functioning of both internal and external systems of quality monitoring and improvement. Reliable and valid information about quality of care should be available to patients, purchasers, and ac-



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