Push for medical school and continuing medical education classes that concentrate on pain and other symptom relief as a distinct and important part of end-of-life care.
A 1993 study by the Eastern Cooperative Oncology Group assessed physicians' attitudes and knowledge about pain control and found that pain assessments were rare in clinic visits and that education on pain management was substandard. Only when new and practicing doctors know that symptom relief is an essential part of practice will patients benefit from current knowledge.
The American Medical Association developed the Education for Physicians on End-of-Life Care (EPEC) project to ensure that practicing physicians have the knowledge and skills to provide the best possible care to dying patients. The curriculum covers key competencies for all doctors, including fundamental skills for palliative care, ethical decision making, symptom management, communication, and psychosocial aspects of care at the end of life. Each meeting lasts for two and a half days and features didactic and interactive learning opportunities. The project aims to educate 250 physician-educators who can then go on to train others and adapt the curriculum to their specific needs.
Advocate for federal research that focuses on the aggressive treatment of pain and other symptoms commonly experienced by dying patients.
Many agencies within the Department of Health and Human Services conduct basic and health services research on serious and life-limiting diseases, yet almost none conduct research on how these diseases affect the end of life and how pain and suffering can be relieved.
Track and educate physicians who underprescribe pain medication.
Physicians who routinely care for dying patients - such as oncologists, geriatricians, and internists - can be expected to prescribe some level of opioids. Those who prescribe insufficient amounts, based on the number of dying patients treated, or prescribe inappropriate drugs or dosages could be sent reeducation materials by state medical boards.
Eliminate duplicate and triplicate prescription forms.
States with duplicate or triplicate prescribing forms for controlled substances should eliminate these forms. Some states, including New York, have recently done so. Studies have shown that when such prescription systems are instituted, the prescribing of Schedule II opioids decreases, while the use of less heavily regulated (and less effective) analgesics increases.
In 1998, New York's governor signed a bill eliminating the requirement for triplicate prescription forms for narcotic pain relievers. Sponsors of the measure expressed hope that the new bill would prompt New York doctors to prescribe pain medication more often for seriously ill patients. The law also changed definitions of "addict" and "habitual user" so that doctors will no longer have to report patients who are legitimately taking controlled substances to the State Department of Health.
Develop electronic monitoring forms for opioid prescriptions.
Some states now use electronic systems to monitor controlled substance prescriptions. With this monitoring, states can readily detect when high volumes of prescriptions have been given for extended periods. The Wisconsin legislature, for instance, created an "interagency diversion prevention and control program" to coordinate the work of state and federal agencies in using existing information and resources to address and identify the sources of drug diversion. More recently, several states, including Massachusetts, Oklahoma, and Nevada, have developed electronic prescription monitoring programs, known as electronic data transfer (EDT) programs. California is testing such a program as a possible replacement for its triplicate prescription program, the oldest of its type in the country. States are studying the effect of EDT programs on drug diversion and on legitimate prescribing for pain and other symptoms.
Reduce malpractice premiums for physicians who take additional courses.
This was a step taken by Copic, a medical liability company that covers 75 percent of Colorado's physicians: Throughout the state, Copic offers one-and-a-half-hour courses on pain management. Doctors who complete the course earn one of five points needed to receive a discount in their malpractice premiums. The course was developed in response to legislative activity surrounding physician-assisted suicide, which led to many reports of untreated pain among dying patients. Among the course's goals are to reduce suffering and to increase health care professionals' ability to recognize and refer patients to pain specialists and to increase their knowledge of pain assessment, pain medications, and auxiliary pain management methods.
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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 ].