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. Patients often depend on health care professionals to manage the varying physical and psychological symptoms that accompany advanced illness. To meet their obligations to their patients, practitioners must hold themselves responsible for using existing knowledge and available interventions to assess, prevent, and relieve physical and emotional distress. When they identify organizational and other impediments to good practice, practitioners have the responsibility as individuals and members of larger groups to advocate for system change.

RECOMMENDATION 3: Because many problems in care stem from system problems, policymakers, consumer groups, and purchasers of health care should work with health care practitioners, organizations, 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. 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. Policymakers and purchasers need to consider both the long-recognized deficiencies of traditional fee-for-service arrangements and the less thoroughly understood limitations of alternatives, including various kinds of capitated and per case payment methods. Particularly in need of attention are payment mechanisms that fail to reward excellent care and create incentives for underor overtreatment of those approaching death.

State medical societies, licensing boards, legislative committees, and other groups should cooperate to review drug prescribing laws, regulations,

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