Health benefits for the terminally ill: reality and perception

The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures

CONTEXT

Cancer is a leading cause of morbidity and mortality in the USA and despite many recent advances in detection and treatment, over half a million cancer patients in this country will die from their disease each year.

OBJECTIVE

Using cancer as a prototype, we provide a conceptual framework to identify and review barriers to optimal end-of-life care and propose examples of linked process and outcome measures that could be used to evaluate whether standards of optimal end-of-life care are being achieved.

METHODS

We propose a conceptual model of end-of-life care and use this model to review the published literature to identify the key goals of optimal end-of-life care and summarize existing barriers to optimal end-of-life care. We then provide examples of process and outcome measures linked to the goals of optimal end-of-life care and domains within the conceptual framework.

RESULTS

Within all components of care at the end-of-life--societal attitudes, health care system(s), providers, and patients and their families--there are significant barriers to the quality of care. Some of the most critical barriers to optimal care at the end-of-life in the USA are limited availability, and coverage of, co-ordinated service delivery; poor provider communication and diagnostic skills; limited opportunities for training in palliative care; patient fears and attitudes towards the sick role, and a lack of, or inadequate health insurance. Proposed patient, provider, and system level measures of the quality of care were guided by goals of optimal end-of-life care, and focus on communication about prognosis and risks and benefits of treatment, development of clear and informed treatment goals, delivery of services consistent with treatment goals, and promotion of quality of life.

CONCLUSIONS

At present, there are substantial societal, health care system, provider, and patient barriers to obtaining optimal cancer care at the end-of-life. Ongoing discussions about appropriate measures of the quality of end-of-life care are gaining momentum, however. The proposed process and outcome measures for assessing optimal end-of-life care use cancer as a prototype, but are broadly applicable to other patient populations with life-threatening disease.

Economic influences on end-of-life care: empirical evidence and ethical speculation

Although very little actual evidence on the issue is available, much ethical speculation has been voiced about the probable impact of the current cost containment-oriented economic climate in the United States on decisions that are being made and implemented in the context of end-of-life medical care. This article, after noting that numerous factors besides money drive the behavior of various actors in the health care system, turns to the economic influences on care for dying patients. These influences, both real and imagined, may be manifested in the amount of de facto health care rationing by age that occurs, the prevalent fears of older persons regarding both overtreatment and undertreament, the financial expectations as well as disappointments emanating from the practice of advance medical planning, and the paucity of options from which many impoverished individuals must choose at the end of their lives. It is too early to judge specifically the impact of managed care on end-of-life decisions, but positive opportunities as well as perils may materialize.

Improving HIV/AIDS services through palliative care: an HRSA perspective. Health Resources and Services Administration

There has been a dramatic shift of the human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) epidemic into poor, marginalized, and minority communities in the US. At the same time, the availability of new highly active antiretroviral treatments has made it possible for a large number of individuals to live for a much longer time with their disease. A net result is that the US is faced with an increasing number of people who are living with HIV/AIDS and are dependent on publicly supported health care services. In this paper, we review the palliative care efforts of the federal agency, the Health Resources and Services Administration (HRSA), responsible for providing Ryan White CARE Act HIV/AIDS care to medically underserved populations. In addition to supporting traditional hospice care, HRSA's HIV/AIDS Bureau has begun a series of initiatives that apply a broader concept of palliative care to its HIV programs in hospital- and community-based settings. Our interest is not to substitute palliation for access to new HIV therapies, such as highly active antiretroviral treatments, but to ensure that our health delivery systems attend to the alleviation of symptoms and suffering along with the provision of antiretroviral and other necessary treatments. HRSA's HIV/AIDS Bureau is organizing a broader provision of palliative care for its clients and actively contributing to improving care for the disenfranchised internationally.