There is evidence of widespread quality problems in end-of-life care, especially in the area of pain management. The elderly, women, and members of racial or ethnic minority groups are more likely than others to have poor pain relief, which appears to be due to a combination of factors: poor palliative care practices on the part of providers, attitudes of patients (e.g., stoicism), and miscommunication between patients and health care providers.

BOX 3.1 "Recommendations and Future Directions" from Approaching Death: Improving Care at the End of Life

  1. People with advanced, potentially fatal illnesses and those close to them should be able to expect and receive reliable, skillful, and supportive care.
  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.
  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:
    1. strengthen methods for measuring the quality of life and other outcomes of care for dying patients and those close to them;
    2. develop better tools and strategies for improving the quality of care and holding health care organizations accountable for care at the end of life;
    3. 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
    4. reform drug prescription laws, burdensome regulations, and state medical board policies and practices that impede effective use of opioids to relieve pain and suffering.
  4. Educators and other health professionals should initiate changes in undergraduate, graduate, and continuing education to ensure that practitioners have the relevant attitudes, knowledge, and skills to care for dying patients.
  5. Palliative care should become, if not a medical specialty, at least a defined area of expertise, education, and research.
  6. The nation's research establishment should define and implement priorities for strengthening the knowledge base for end-of-life care.
  7. A continuing public discussion is essential to develop a better understanding of the modern experience of dying, the options available to dying patients and families, and the obligations of communities to those approaching death.

SOURCE: IOM, 1997.

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