Improving Palliative Care

The need to enhance palliative care of dying patients has become apparent in the United States. Although hospitals have traditionally focused on treating episodic acute illness and prolonging life, 65% of adults in the United States now die in hospitals [1]. Data suggest that hospitals and physicians are not equipped or trained to handle the medical and psychosocial problems that face those who are dying [2-5]. Although the barriers to achieving a peaceful death are many, they can be grouped into three broad categories: professional knowledge of and skills in palliative medicine, professional and public attitudes about the goals of medicine, and financial and structural attributes of the health care industry. In this article, we outline a series of strategies that are designed to overcome these barriers. Improving Professional Knowledge of and Skills in Palliative Medicine Palliative medicine has been defined as the study and management of patients with active, progressive, far advanced disease, for whom the prognosis is limited and the focus of care is the quality of life [6]. In the United States, curricula at medical schools and in residency training programs contain minimal formal courses on death and dying [7-15]. The result has been inadequate professional knowledge of palliative medicine [7, 16, 17]. For example, the failure of medical professionals to adequately treat pain has been consistently demonstrated in diverse patient populations [3, 4, 7, 18], and physician-initiated discussions about the goals of medical care at the end of life seldom occur [4, 5, 19]. Enhancing palliative care education at all levels of professional training is a necessary first step in changing physician behavior [20]. Curricula in palliative medicine have been published by numerous organizations [9, 21-27] and should be combined with efforts to teach the difficult process of prognostication to better enable physicians to time the initiation of palliative interventions [28, 29]. To overcome the well-documented difficulty that physicians have in talking with patients about end-of-life care [2-4, 30-33], curricula must address the issues of physicianpatient communication and acknowledge the influence of fear of death on those who become physicians [34-36]. It is important to teach that patient suffering can be alleviated by applying existing knowledge and that the time before death can be a rich and rewarding opportunity for communication between patients and their families [37, 38]. Palliative care must become an integral component of primary medical care so that the arbitrary dichotomy between the medical care of persons who are perceived as having curable or chronic illnesses and those who are recognized as dying becomes a continuum, with palliative measures gradually taking precedence over life-prolonging efforts when death is imminent. Practical means of accomplishing these objectives include establishing a staff of teaching mentors who are appropriately compensated, creating endowed chairs and professorships, and continuing to provide financial support for research and programmatic experimentation. Mandated inclusion of didactic curricula and clinical teaching programs on palliative care in medical school and residency training programs, and inclusion of these topics on board certification examinations and in residency review committee and hospital accreditation requirements, have already been initiated and will strongly influence teaching priorities [39]. Others have suggested practice guidelines and continuous quality-improvement programs as ways to enhance education in and delivery of palliative care [27, 40-42]. Several educational initiatives in palliative medicine have begun in the United States. The Project on Death in America, which was founded by The Open Society Institute, supports a faculty scholars program that fosters leadership in palliative medicine at major teaching hospitals [43]. Both federal sources and private foundations are funding research and educational initiatives in palliative care [44, 45], and efforts by the American Board of Internal Medicine to include topics on palliative medicine in residency review criteria and on certification examinations are under way [25, 46]. Attitudinal Influences on the Delivery of Palliative Care Attitudinal influences on delivery of care to dying persons include confusion about decisions to forego life-sustaining treatment and euthanasia, fear and denial of death among medical professionals and the public, and a belief that prolongation of life is the predominant goal of medicine. The current debate on physician-assisted suicide has revealed public and professional disagreement and confusion about the difference between forgoing life-sustaining therapy (a legal right of every competent patient) and active euthanasia. Technologies permitting life support in severely ill patients have become standard practice at the end of life and have redefined what used to be clearly terminal situations as conditions for which physiologic life can be prolonged for variable and sometimes lengthy periods [47]. Perhaps as a result of the frequent use of such technologies in dying patients, many medical professionals may incorrectly believe that a decision to forgo life-sustaining treatment is equivalent to active euthanasia [48-50]. These beliefs constrain health care professionals to use any technologies that might prolong life because a conscious choice to withhold intervention and allow the patient to die of his or her underlying disease is perceived as euthanasia. Similar uncertainty surrounds the principle of double effect (when a dose of analgesics or sedatives given to control pain and discomfort may also hasten death) [48-50]. Despite the unequivocal ethical and moral acceptance of the principle of double effect by the medical community [51, 52], health care professionals remain unsure of the distinction between the administration of sufficient medication to treat suffering in dying patients and euthanasia. [48-50]. Such uncertainty results in inadequate control of distressing symptoms in terminally ill patients [3, 4, 7, 50] and may contribute to the public's increasing demand to legalize physician-assisted suicide [53-55]. Addressing attitudinal influences on the care of dying patients requires fundamental shifts in the prevailing life-prolongation ethos of medicine. Some options that might achieve a change of attitude include 1) educating health care professionals and the general public about the legitimacy of prescribing analgesia and withdrawing life-sustaining treatments and the distinction between these decisions and active euthanasia; 2) establishing standards for futile care through consensus conferences and recommendations from professional organizations; 3) educating the public through media [56] on the limitations of medical technology and through improved physicianpatient communication on the ability to achieve a peaceful death [36]; and 4) adopting more widespread use of advance directives as a tool to promote societal acceptance of the inevitability of death and the informed refusal of life-sustaining treatment [56]. Although some [4] but not all [5] recent studies suggest that advance directives have a limited effect on patient care, few of the studies were designed to assess the effect of advance directives on clinical outcomes. More public and professional familiarity with advance directives may be necessary before changes in outcomes can be measured. However, recent studies [4, 5] and news articles [57] clearly indicate that physicians must be educated to routinely ask patients about their wishes for medical care and to recognize that physicians are legally and morally bound to honor those requests [5, 58, 59]. Such communication is especially pressing in the context of terminal illness, when the achievement of a peaceful death assumes priority over prolongation of life. To restore a balance between a physician's obligation to prolong life and obligation to relieve suffering, a peaceful death must be acknowledged as a legitimate goal of medicine and as an integral part of a physician's responsibilities. The literature suggests that some physicians view the care of dying patients as beyond their responsibility [60, 61] and, according to one study [62], as a role that interfered with their medical education. This view is widely (although unconsciously) supported by medical school professors who lack knowledge of palliative medicine, thereby reinforcing the prevailing trend against recognizing and attending to the needs of dying patients [17, 63]. Barriers Presented by the Health Care Industry The organizational and structural characteristics of a health care delivery system can promote or inhibit palliative care for persons who are facing death [64]. Improving physician knowledge of and training in palliative care and changes in attitudes about what constitutes a good death and the value of achieving one can succeed only if concomitant changes in health care delivery support and ratify these efforts. The Joint Commission on Accreditation of Healthcare Organizations recently published standards [65] that include new requirements for palliative care of dying patients (specifying the aggressive and effective management of pain). The commission also addressed the issue of advance care planning and the psychosocial, spiritual, and cultural factors that influence patient care [65]. Such mandates can be powerful stimuli to change the organization and delivery of health care. Recent proposals [66, 67] for establishing inpatient palliative care units in teaching hospitals are another example of restructuring the delivery of health care. Such inpatient palliative care units already exist or are in formation in some centers and at medical schools [25, 68-70]. Enormous pressures for cost-containment in medicine also inhibit palliative care. Length of stay has been s