DYING IN AMERICA
Improving Quality and
Honoring Individual Preferences
Near the End of Life
Committee on Approaching Death: Addressing Key End-of-Life Issues
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
International Standard Book Number-13: 978-0-309-30310-1
International Standard Book Number-10: 0-309-30310-9
Library of Congress Control Number: 2014959553
Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2015 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2015. Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.
COMMITTEE ON APPROACHING DEATH:
ADDRESSING KEY END-OF-LIFE ISSUES
PHILIP A. PIZZO (Co-Chair), Former Dean and David and Susan Heckerman Professor of Pediatrics and of Microbiology and Immunology, Founding Director, Stanford Distinguished Careers Institute, Stanford University, Stanford, California
DAVID M. WALKER (Co-Chair), Former U.S. Comptroller General, Bridgeport, Connecticut
PATRICIA A. BOMBA, Vice President and Medical Director, Geriatrics, Excellus BlueCross BlueShield, Rochester, New York
EDUARDO BRUERA, Professor and Chair, Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
CHARLES J. FAHEY, Marie Ward Doty Professor of Aging Studies Emeritus, Fordham University; Program Officer, Milbank Memorial Fund, Syracuse, New York
PAMELA S. HINDS, Director, Department of Nursing Research and Quality Outcomes, Children’s National Health System; Professor of Pediatrics, The George Washington University, Washington, DC
KARLA F. C. HOLLOWAY, James B. Duke Professor of English and Professor of Law, Duke University, Durham, North Carolina
NAOMI KARP, Senior Policy Analyst, Office for Older Americans, Consumer Financial Protection Bureau, Washington, DC
JEAN S. KUTNER, Gordon Meiklejohn Endowed Professor of Medicine and Associate Dean for Clinical Affairs, University of Colorado School of Medicine; Chief Medical Officer, University of Colorado Hospital, Aurora, Colorado
BERNARD LO, President, Greenwall Foundation, New York, New York
SALIMAH H. MEGHANI, Associate Professor, Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia
DIANE E. MEIER, Director, Center to Advance Palliative Care, Catherine Gaisman Professor of Ethics, and Professor, Department of Geriatrics and Palliative Medicine, The Icahn School of Medicine at Mount Sinai, New York, New York
WILLIAM D. NOVELLI, Professor, McDonough School of Business, Georgetown University; Co-Chair, the Coalition to Transform Advanced Care, Washington, DC
STEPHEN G. PAUKER, Professor of Medicine and Psychiatry, Tufts University School of Medicine; Division of Clinical Decision Making, Informatics and Telemedicine, Tufts Medical Center, Boston, Massachusetts
JUDITH R. PERES, Clinical Social Worker and Policy Consultant, Chevy Chase, Maryland
LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern California, Santa Monica
W. JUNE SIMMONS, President and CEO, Partners in Care Foundation, San Fernando, California
CHRISTIAN T. SINCLAIR, Assistant Professor, Division of Palliative Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
JOAN M. TENO, Professor of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
FERNANDO TORRES-GIL, Professor of Social Work, Professor of Public Policy, and Director of the Center for Policy Research on Aging, Luskin School of Public Affairs, University of California, Los Angeles
JAMES A. TULSKY, Professor of Medicine and Nursing and Chief, Duke Palliative Care, Duke University, Durham, North Carolina
ADRIENNE STITH BUTLER, Senior Program Officer
STEPHANIE H. PINCUS, Scholar-in-Residence
LAUREN SHERN, Associate Program Officer
BRADLEY ECKERT, Research Associate
JIM BANIHASHEMI, Financial Officer
THELMA COX, Administrative Assistant
JUDITH A. SALERNO, President and CEO, Susan G. Komen Breast Cancer Foundation
NEIL WEISFELD, Writer
VICTORIA WEISFELD, Writer
RONA BRIERE, Editor
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Susan Block, Harvard Medical School
Christine K. Cassel, National Quality Forum
Myra J. Christopher, Center for Practical Bioethics
Don E. Detmer, University of Virginia School of Medicine
Kathleen A. Dracup, University of California, San Francisco, School of Nursing
Alexandra Drane, Eliza Corporation
Thomas Edes, U.S. Department of Veterans Affairs
Betty Ferrell, City of Hope Medical Center
Anita K. Jones, University of Virginia
Judith R. Lave, University of Pittsburgh
Joanne Lynn, Center on Elder Care and Advanced Illness, Altarum Institute
Willard G. Manning, The University of Chicago
Charlie Sabatino, American Bar Association Commission on Law and Aging
Tracy Schroepfer, University of Wisconsin–Madison
Mark D. Smith, California HealthCare Foundation
VJ Periyakoil, Stanford University School of Medicine
James W. Vaupel, Max Planck Institute for Demographic Research
Joanne Wolfe, Children’s Hospital Boston
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Bradford H. Gray, The Urban Institute, and Donald M. Steinwachs, Johns Hopkins University. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
In spring 2009, bills for what eventually became the Patient Protection and Affordable Care Act were being drafted in the House and Senate. A bipartisan group of representatives sponsored a provision in the House version of the bill that would have authorized Medicare to pay doctors who counsel patients about living wills, advance directives, and options for end-of-life care. AARP endorsed the provision. However, pundits, bloggers, op-ed writers, talk show hosts, and other legislators claimed the provision would lead to government-sponsored euthanasia and heartless “death panels” that would adjudicate who shall live. The administration distanced itself from the proposal, which never found its way into the law.
Still, the specter of death panels had staying power. One 2011 poll of American adults found that 23 percent believed the Affordable Care Act gave government the power to make end-of-life decisions on behalf of seniors, and 36 percent were not sure. When Donald Berwick became commissioner of the Centers for Medicare & Medicaid Services, he attempted to authorize payment for counseling on advance care planning as part of annual wellness visits provided for under the Affordable Care Act. This provision was to go into effect on January 1, 2011. By January 4, the administration had withdrawn this provision. Doctors would still be free to talk with patients about living wills, hospice care, or other end-of-life concerns, but they could not bill Medicare for this service.
The controversy on this topic and the political desire to avoid it do not alter the fact that every person will face the end of life one day, and many have had hard experience with the final days of a parent, a spouse, a child, a sibling, another relative, or a dear friend. At a time when public
leaders hesitate to speak on a subject that is profoundly consequential for the health and well-being of all Americans, it is incumbent on others to examine the facts dispassionately, assess what can be done to make those final days better, and promote a reasoned and respectful public discourse on the subject.
With these goals in mind, the Institute of Medicine undertook the study documented in this report. A public-spirited donor, wishing to remain anonymous, came forward to support this study. We are grateful to this donor and to the outstanding and diverse committee, skillful co-chairs, and able staff who produced this comprehensive and compelling report. We hope it will stimulate the personal and public conversations and changes necessary to honor individual preferences and meet everyone’s needs at the end of life.
|Harvey V. Fineberg, M.D., Ph.D.||Victor J. Dzau, M.D.|
|Former President, Institute of Medicine||President, Institute of Medicine|
Death is ultimately a deeply personal human experience that evokes different reactions, emotions, and perceptions from individuals, families, and communities throughout the life cycle. The perception of death is different for children, adults seen to be in the prime of life, and those in the later years of life, but it is also highly subjective and deeply personal irrespective of when it occurs along the life journey.
Perceptions and views about death are also influenced by a wide array of social, cultural, economic, geographic, spiritual, and religious beliefs and experiences. While most people have given thought to how they would like to die, many have found it difficult to communicate those views and choices to family and loved ones, and in many cases, family and loved ones have their own perceptions and views about death that can influence discussions about dying. Even when individuals and families are aligned, societal norms, expectations, and requirements are not always concordant with the patient’s wishes and choices. No one really knows whether, in the end, the death of a loved one occurred with the dignity that was hoped for, or to what degree the dying experience was marred by pain, fear, and discomfort, emotional or physical.
Unfortunately, the evidence demonstrates that even if one completes an advance directive or has a discussion on the subject with family and loved ones, it tends to be separated from the time of dying by months, years, or even decades. Most people envision their own death as a peaceful and an ideally rapid transition. But with the exception of accidents or trauma or of a few illnesses that almost invariably result in death weeks or months after diagnosis, death comes at the end of a chronic illness or the frailty
accompanying old age. Few people really have the opportunity to know when their death will occur.
Even though death is very much part of the cycle of life and the journey to physical dying begins with the inception of living, thinking and talking about one’s own death usually remains in the background, at least until its prospect become more probable or imminent. Of course, death can occur without warning, as it does with assaults and trauma, whether accidental or purposeful. Sudden death can also occur with certain illnesses, but death most often is more insidious and the result of a chronic illness or disease. And while it is true that the likelihood of death increases with age, it is also true that death occurs throughout the life cycle. As a discipline, moreover, medicine is filled with examples of faulty predictions offered prospectively, sometimes too tentatively and often too definitively. Humility about the inability to predict the actual time of death is an important attribute for the health care professional regardless of discipline or area of expertise.
As longevity becomes more common and disease leading to early and frequent death becomes less prevalent, it is easy to be lulled into the belief that death may be postponed or, as some prominent figures have forecast, even avoided. To be sure, advances in science and medicine and the burgeoning field of stem cell biology and regenerative medicine offer the prospect of delaying death to a much greater extent than previously thought possible. After all, in just one century, life expectancy in the United States rose from age 47 to 78, and individuals over 90 are now the most rapidly growing (albeit still a small) portion of the population. It appears probable that many children being born today will still be active at the turn of the next century. Still, death will inevitably occur.
While optimism about the prospect of continued life abounds, fears about death—or at least how it can happen or who governs it—can easily be stoked. Witness the impact of the unfortunate (although purposeful) choice of the words “death panels” during the heated debate surrounding the passage of the Patient Protection and Affordable Care Act in August 2009. Those two words conveyed that individual choice in how one faces dying and death could be supplanted by a distant and uncaring bureaucracy. While this fear was unfounded, its very presence and the ease with which it was evoked underscore the sensitivity of the topic of their personal mortality for many Americans, especially the elderly. That 20 percent of the U.S. population will be older than 65 by 2050 further demonstrates the importance of finding ways to improve the quality of the final days of life and honoring individual choices about end-of-life issues and concerns.
The Institute of Medicine (IOM) has played an important role in conversations and policies surrounding end-of-life care. In 1997, the IOM produced the report Approaching Death: Improving Care at the End of Life, and in 2003, it extended the conversation to pediatrics in its report When
Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Each of these reports has had a major impact on end-of-life care, and a number of new programs, policies, providers, and systems of care have developed as a consequence. While many of the observations from these two major reports remain relevant, the United States has undergone many changes in its demography, in health care outcomes, and in the costs of health care delivery since these reports were published. Indeed, the past several years have witnessed a heightened focus on health care in this country, on what does and does not work, and on how systems of care vary across the population and differ from those of other developed countries. There is no question that while the cost of care in the United States is the highest in the world, the outcomes of care are not superior to those in other nations in any dimension or metric. And while cost should not by itself drive how high-quality, evidence-based care is delivered, it must be part of the dialogue. This applies to the care provided throughout the life course.
In 2012, the leadership of the IOM determined that another study on the end of life was needed given the intense ongoing dialogue surrounding health care reform in the United States. Dr. Harvey Fineberg, who was then president of the IOM, determined that this study should be conducted by a committee led by co-chairs whose collective expertise bridged the spectrum of the health care debate. One of us (Philip A. Pizzo) has spent decades caring for children and families with catastrophic disease facing the prospect of death. He has also been deeply steeped in biomedical research and the leadership of two major academic medical centers. The other (David M. Walker) has extensive experience in connection with fiscal responsibility and health care policy issues. His leadership experience spans all three major sectors of the U.S. economy. Of course each of us also brought personal history and experiences to the endeavor that resulted in areas of overlap, synergy, and sometimes difference in perspective. Our consensus committee included 19 other members, each with deep expertise related to various aspects of the medical, social, economic, ethical, and spiritual dimensions surrounding death.
Along with our highly competent study director, Dr. Adrienne Stith Butler, the committee held six meetings and hosted numerous discussions by phone, email, and other forms of communication. Those discussions generated both heat and light and gave witness to the strong and sometimes polarizing views that are engaged around the topic of the death and dying of vulnerable patients and families. Understandably, there were times when dialogues and debates seemed to reach an impasse, reflecting the larger public conversation (or the lack thereof) about various dimensions of the end of life. At the same time, those discussions helped sharpen our understanding of the issues involved and ultimately enabled us to reach consensus
on conclusions and recommendations that we hope will further shape the national conversation on dying in America.
As committee co-chairs, we owe a deep debt of gratitude to all the committee members for their time, energy, passion, commitment, and diligence. In the end, we share a common goal of improving the individual and highly personal experience of dying in America. We also want to thank the IOM members and staff who provided invaluable support for this study. Dr. Judith Salerno, who was Leonard D. Schaeffer executive officer of the IOM when our work commenced, left the IOM to become CEO of the Susan G. Komen Breast Cancer Foundation. Without missing a beat, she sustained her commitment and dedication to the committee’s work, as evidenced by her active and continued participation in committee meetings, discussions, and debates. We also want to thank Dr. Stephanie Pincus for her commitment and important insights, as well as Thelma Cox, Bradley Eckert, and Lauren Shern for their support. In addition, we were the beneficiaries of the writing and insights of Neil and Vicki Weisfeld, who enabled our discussion and debates to be framed in words with substance. Each of these many individuals exceeded expectations and enabled our progress to be sustained and successful. We also want to thank the numerous individuals who provided public testimony in person or in writing. The insights we received were invaluable and helped ground us in reality. It is our hope that this report will capture those insights and ultimately lead to improvements in end-of-life care and the experience of dying for all.
Philip A. Pizzo, Co-Chair
David M. Walker, Co-Chair
Committee on Approaching Death:
Addressing Key End-of-Life Issues
Several individuals and organizations made important contributions to the study committee’s process and to this report. The committee wishes to thank these individuals, but recognizes that attempts to identify all and acknowledge their contributions would require more space than is available in this brief section.
To begin, the committee would like to thank the sponsor of this study. Funds for the committee’s work were provided by a donor that wishes to remain anonymous. The committee gratefully acknowledges the contributions of the many individuals and organizations that assisted in the conduct of this study. Their perspectives were valuable in understanding critical topics with regard to end-of-life care. The committee thanks those individuals who provided important presentations and oral testimony at its open workshops. Appendix A lists each of these individuals and their affiliations. Written testimony received from hundreds of individuals and organizations also helped the committee understand the experiences of those who are likely approaching death and their family members and caregivers, as well as health care providers, and the perspectives of many stakeholder organizations. Appendix C provides a summary of this input. We would also like to thank the following Institute of Medicine (IOM) staff for their valuable contributions to this study: Jim Banihashemi, Daniel Bethea, Marton Cavani, Laura Harbold DeStefano, Chelsea Frakes, Greta Gorman, Jim Jensen, Nicole Joy, Abbey Meltzer, and Jennifer Walsh. The committee is grateful for the time, effort, and valuable information provided by all of these dedicated individuals and organizations.
The committee would like to thank the authors whose commissioned
papers added to the evidence base for this study: Haiden A. Huskamp, Harvard Medical School, and David G. Stevenson, Vanderbilt University School of Medicine; Melissa D. Aldridge and Amy S. Kelley, Icahn School of Medicine at Mount Sinai; and Chris Feudtner, Wenjun Zhong, Jen Faerber, and Dingwei Dai, Children’s Hospital of Philadelphia, and James Feinstein, Northwestern University. The committee is also grateful to Bryan Doerries, artistic director for Outside the Wire, and to T. Ryder Smith and Alex Morf, who performed at an event sponsored by the IOM and the committee at the Chautauqua Institution. Great thanks are owed as well to Sherra Babcock, who first extended the invitation for the IOM’s participation at the Chautauqua Institution, and George Murphy, who was instrumental in coordinating the logistics of the event. The committee is also grateful to Maureen Valenza from The University of Texas MD Anderson Cancer Center and Mira Engel from the Stanford University School of Medicine, who helped to coordinate the committee’s off-site meetings.
This page intentionally left blank.
American Association of Colleges of Nursing
American Academy of Hospice and Palliative Medicine
Association of American Medical Colleges
American Board of Internal Medicine
American Board of Medical Specialties
Patient Protection and Affordable Care Act
associate certified chaplain
Aid to Capacity Evaluation
Accreditation Council for Graduate Medical Education
Administration for Community Living
accountable care organization
Assessing Care of Vulnerable Elders initiative
activity of daily living
American Geriatrics Society
Agency for Healthcare Research and Quality
Administration on Aging
Acute Physiology and Chronic Health Evaluation
Association of Professional Chaplains
American Public Health Association
Associated Press-National Opinion Research Center
Alternative Quality Contract
American Recovery and Reinvestment Act of 2009
American Society of Health-System Pharmacists
Assistant Secretary for Planning and Evaluation
board certified chaplain
Board of Chaplaincy Certification Inc.
board certified chaplain-palliative care certified
Medicare Bundled Payments for Care Improvement Initiative
Board of Pharmacy Specialties
Center to Advance Palliative Care
Consumer Assessments and Reports of End of Life
Cancer, Admissions ≥2, Residence in a nursing home, Intensive care unit admit with multiorgan failure, ≥2 Noncancer hospice Guidelines
Congressional Budget Office
complex chronic condition
Community Conversations on Compassionate Care
critical care unit
Centers for Disease Control and Prevention
California HealthCare Foundation
congestive heart failure
Children’s Health Insurance Program
Children’s Program of All-Inclusive Coordinated Care for Children and Their Families
Children’s International Project on Palliative/Hospice Services
Community Living Assistance Services and Supports Act
Centers for Medicare & Medicaid Services
chronic obstructive pulmonary disease
do not resuscitate
doctor of osteopathy
essential health benefit
End-of-Life Nursing Education Consortium
emergency medical services
emergency medical technician
Educate, Nurture, Advise Before Life Ends intervention
Education in Palliative and End-of-life Care Program
Early Periodic Screening, Diagnosis, and Treatment
end-stage renal disease
U.S. Food and Drug Administration
gross domestic product
Geriatric Resources for Assessment and Care of Elders
Hopkins Competency Assessment Test
home- and community-based services
Healthcare Cost and Utilization Project
Healthcare Effectiveness Data and Information Set
U.S. Department of Health and Human Services
Health Insurance Portability and Accountability Act
Hospice Item Set
Health Information Technology for Economic and Clinical Health Act
Hospice Medical Director Certification Board
hospice and palliative medicine
Hospice and Palliative Nurses Association
Hospice Quality Reporting Program
Health and Retirement Study
instrumental activity of daily living
implantable cardioverter defibrillator or International Classification of Diseases
intensive care unit
Institute for Healthcare Improvement
Initiative for Pediatric Palliative Care
The Henry J. Kaiser Family Foundation
Kids’ Inpatient Dataset
Medical Expenditure Panel Survey
Medicare Prescription Drug Improvement and Modernization Act of 2003
Medical Orders for Life-Sustaining Treatment
Medicare Shared Savings Program
National Association of Social Workers
National Board for Certification of Hospice and Palliative Nurses
National Comprehensive Cancer Network
National Center for Health Statistics
National Cancer Institute
National Council on Aging
National Consensus Project for Quality Palliative Care
National Committee for Quality Assurance
National Data Set
Nationwide Emergency Department Sample
National Healthcare Decisions Day
National Hospice and Palliative Care Organization
National Institutes of Health
National Institute of Nursing Research
National Palliative Care Research Center
National Quality Forum
Organisation for Economic Co-operation and Development
Program of All-inclusive Care for the Elderly
Patient Aligned Care Team
Palliative Prognostic score
practice-based research network
Palliative Care Leadership Center
Patient-Centered Outcomes Research Institute
American Medical Association-Physician Consortium for Performance Improvement
Palliative Care Research Cooperative Group
Project on Death in America
Physician Data Query
Prepare, Embrace, Attend, Communicate, Empower Project
Pediatric Early Care program
Program to Enhance Relational and Communication Skills
Pediatric Health Information System
Prognosis in Palliative Care Study
Physician Orders for Life-Sustaining Treatment
pediatric palliative care
Pediatric Palliative Care Network
Premier Perspective Database
Quality Incentive Program
Robert Wood Johnson Foundation
sustainable growth rate
Supplemental Nutrition Assistance Program
skilled nursing facility
Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments
Understanding Treatment Disclosure
U.S. Department of Veterans Affairs
World Health Organization