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Care of the Dying in 'Urgent Need of Repair'

Care of the Dying in 'Urgent Need of Repair'

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 Hospital Association.

"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.

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