board practices, and physician attitudes and practices to identify problem areas and then devise revisions in unduly burdensome statutes and regulations. Such regulatory change is not enough. It must be accompanied by education to increase knowledge and correct misperceptions about the appropriate medical use of opioids and about the biological mechanisms of opioid dependence, addiction, and pain management.

The committee identified characteristics of community care systems that would more effectively and reliably serve dying patients and their families. "Whole-community" approaches to end-of-life care would include a mix of programs, settings, personnel, procedures, and practices that extend beyond health care institutions and policies to involve entire communities. The goals would be to make effective palliative care available wherever and whenever the dying patient is cared for; help dying patients and their families to plan ahead and prepare for dying and death; and establish accountability for high quality care at the end of life. Box S.1 shows key features of a whole-community system for end-of-life care. A system with these components would reflect the understanding that there is not just one way to care for dying patients and that some flexibility is needed to respond to patients who do not comfortably fit the routines and standards that serve most patients well. Clearly, such a system represents an aspiration. The model implies cooperative effort involving public and private agencies on multiple levels—community, state, and national.

RECOMMENDATION 4: Educators and other health professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have relevant attitudes, knowledge, and skills to care well for dying patients. Dying is too important a part of life to be left to one or two required (but poorly attended) lectures, to be considered only in ethical and not clinical terms, or to be set aside on the grounds that medical educators are already swamped with competing demands for time and resources. Every health professional who deals directly with patients and families needs a basic grounding in competent and compassionate care for seriously ill and dying patients. For clinicians and others to be held truly accountable for their care of the dying, educators must be held accountable for what they teach and what they implicitly and explicitly honor as exemplary practice. Textbooks and other materials likewise need revision to reflect the reality that people die and that dying patients are not people for whom "nothing can be done." Box S.2 outlines the fundamental elements of professional preparation for skillful, compassionate, and respectful care at the end of life.

RECOMMENDATION 5: Palliative care should become, if not a medical specialty, at least a defined area of expertise, education, and re-

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