The good news about end-of-life care is that any health care organization in the country can take immediate steps to improve how it cares for dying patients and those who love them. These important changes need not wait for one more study, meeting, survey, or signature - health care providers who understand how to use the rapid-cycle model can begin using it this week (or by the time they've finished this book!). Each chapter in this section explains why particular changes are needed and how improvement teams can use the Plan-Do-Study-Act model to achieve them.
Although pain is a frequent problem for patients, it often goes untreated or undertreated. The reasons for this problem are complex, yet some solutions - such as making pain a fifth vital sign or asking patients to set their own target levels for pain intensity - are straightforward. Chapter 3 describes ways organizations can better prevent, assess, and treat pain.
Shortness of breath, or dyspnea, is a common symptom at the end of life, occurring as part of the disease or in the course of ventilator removal. Dyspnea, like pain, is frequently untreated. Chapter 4 describes ways to make its treatment routine and patient comfort a priority.
In a live-for-today society, people find it hard to make plans for the future; serious and complex illness makes advance care planning an even more daunting task for most people. By expanding popular notions of what advance care plans are and should be (beyond the useful but limited living will or the idea that advance plans are simply about "pulling the plug"), health care providers can help patients and families anticipate problems, talk about alternatives and preferences, and map a treatment plan and goals for living well. Chapter 5 describes steps patients, families, and health care providers can take to improve advance care planning.
Serious and complex illness often raise issues of meaningfulness, purpose, and spirituality. Chapter 6 discusses ways to support patients and families and their relationships with one another. Some families appreciate simple gestures, such as being given a pager so they can take a rest while keeping vigil in an ICU; some appreciate visits from hospital chaplains or other spiritual leaders; still others benefit from grief and bereavement programs.
The concluding chapter in this section focuses on ways to improve continuity of care, so that patients do not feel like numbers or diseases or billing codes because organizations do not treat them as if they were. Basic steps, such as preventing in-hospital transfers during the final hours of life, can do much to promote comprehensive care.
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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.
For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].