fact, serve different goals for different patients. It is also consistent with Chapter 1's definition of palliative care as involving the prevention and relief of suffering through early identification and impeccable assessment and treatment of symptoms, both physical and psychological.

Mixed management near death may be commonplace in the care of the frail elderly but does not seem to be as frequently articulated or practiced with those facing the end of life with chronic organ system failure or cancer. It seems likely that attending to "ongoing negotiation" rather than one dominant goal of care might well merit development for these patients.

This need is underscored by the fact that prognosis for many courses to death are ambiguous, even very near to death. In one study of severe congestive heart failure, half of patients who died were—on the day before they died—assigned prognoses of a greater than 50-50 change to live two months (Lynn et al., 1996). Rather than counsel patients about a likely imminent downward trajectory, the team should ensure that the patient understands the limits of what medicine can do to prolong life and that all attempts will be made to palliate and prevent suffering. Clinicians need to engage patients and families in realistic discussions about the risks of death and provide them full opportunity to ask questions and make plans. Because people will vary in what they want to know and decide, clinicians need to be especially sensitive to patient cues about their desires.

Conclusion

Care at the end of life has both a specific focus on those approaching death and a very expansive interest in the patient's family and friends; the health care team; and, ideally, the larger, caring community that tends to its members in both health and sickness. This caring community most immediately includes neighbors, co-workers, employers, and members of religious and voluntary service organizations, but it also extends to those in government and communications whose policies or images may nourish the caring spirit or subvert it.

Major objectives of end-of-life care are to prevent and relieve pain and other distressing symptoms while respecting patient preferences and dignity and offering concern and reassurance to patients and those close to them. Care at the end of life attends to physical, emotional, spiritual, and practical dimensions of the experience of life-threatening illness. It involves a continuing process of assessing and reassessing needs and the therapies and other assistance intended to help patients live well while dying.

The experience of dying is significantly determined by systems of care. They can powerfully support care along all its dimensions or they can put formidable obstacles in the way of good care at the end of life. The next chapter explores the structures of health care that shape how people die.



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