The Institute for Healthcare Improvement (IHI) has announced the formation
of a collaborative of health care organizations that will work together
to improve care at the end of life, an issue that many health-care leaders
in the United States agree is in urgent need of repair. Hospitals, nursing
homes, managed care organizations, and hospices from across the United
States and Canada are invited to apply for participation in the collaborative,
which was begun in July 1997. The collaborative is cosponsored by the American
"With such good intentions, how can so much go wrong? Study after
study finds that patients, families, doctors, and other health professionals
often want the same qualities in care at the end of life: dignity, comfort,
communication, and the company of loved ones," said Donald Berwick,
MD, president and chief executive officer of the Institute for Healthcare
Improvement. "And yet, time and again, we seemed trapped in desperate
struggles and wasted energies that help no one. Sensitive, respectful care
at the end of life can be achieved. Now we need to assure that it happens,"
Dr. Berwick said. According to Joanne Lynn, MD, chair and director of the
Center for Improving Care of the Dying at George Washington University,
health-care providers want to do better in caring for dying patients, and
they know that the public demand for improvement has never been stronger.
"Because the health-care system so often fails them, terminally
ill people and others near the end of life have come to view physician-assisted
suicide as their way to escape," said Dr. Lynn. "We have the
knowledge to improve and the moral and ethical obligation to provide people
with comfort, compassion and a meaningful experience as their lives come
to a close."
"There are health-care organizations that have significantly reduced
the percentage of cancer patients with serious pain down to less than 10%
of all patients experiencing pain," said Dr. Lynn. "Yet, such
knowledge is not widely replicated in usual health-care systems. The collaborative
aims to make such knowledge widespread," said Dr. Lynn. According
to Dr. Lynn, the collaborative will learn from organizations that have
successfully managed conditions such as congestive heart failure at the
end of life while reducing hospital utilization by one-third. Often, medical
interventions for such conditions are unwanted by patients, do not enhance
patient comfort, and are costly. Another emphasis will be on the ways nursing
homes have worked cooperatively with dying patients and their families
in evaluating the decision to be transferred to a hospital.
Nursing Home vs Hospital
"At one nursing home the rate of decision against transfer to a
hospital went from very rare to nearly 75% of patients," said Dr.
Lynn. "A good nursing home is a much more comfortable place than a
hospital for a patient at the end of life. By working with patients and
their families to increase comfort and reduce transitions, the decision
to remain in the nursing home is often in the patient's best interest."
Another area of focus will be on educating and supporting health-care professionals
who are often uneasy with the clinical, ethical, and spiritual care needed
by dying patients, as well as the legal ramifications of that care.
To apply for the Care at the End of Life Collaborative or for further
information, call the Institute for Healthcare Improvement at 617-754-4800.