Sick To Death > Chapter 3 > Practice Guidelines and Audit Tools
A few initiatives have aimed to establish standards of practice for those who are very old and/or very sick. For example, the Assessing Care of Vulnerable Elders (ACOVE) Project convened an expert panel of physicians to develop a set of evidence-based quality indicators for vulnerable elders (Wenger, Shekelle, and the ACOVE Investigators 2001). Vulnerable elderly were defined as those older than sixty-five, living in the community, and at high risk for functional decline or death. The project identified end-of-life care as a priority concern (Wenger and Rosenfeld 2001) and developed indicators for discussing and documenting surrogate decision makers, patient-care preferences, and advance directives, as well as for starting and documenting treatments to relieve shortness of breath, pain, and spiritual distress. The panel recommended the use of these quality indicators to compare the care provided by different health- care delivery systems and to evaluate changes over time or in response to intervention. The ACOVE investigators have shown that their measures of quality are met only about half the time (Wenger et al. 2003).
The Last Acts project, a national program office for the Robert Wood Johnson Foundation's projects to improve end-of-life care, convened a palliative-care task force, which promulgated "Precepts of Palliative Care" as the basis for needed reforms (Last Acts 1997). Those precepts call for respect for patients' goals and choices, comprehensive caring services, interdisciplinary teamwork, support for caregivers, and systems capable of supporting good care. Similarly, fifteen professional organizations have signed a statement of core principles for end-of-life care (Cassel and Foley 1999), and Last Acts compiled more than seventy statements on end-of-life care issues by more than forty organizations (Phillips, Sabatino, and Long 2001).
Guidelines for palliative care and pain management have been developed and used to improve end-of-life care. The American Pain Society promoted the concept of pain as a fifth vital sign, which has been widely adopted (American Pain Society 1995). JCAHO has added this assessment to its standards, and pain is now routinely assessed at hospitals nationwide. In 1999, the Veterans Health Administration added pain assessment to its vital sign assessments (Lynch Schuster 1999). The veterans program also launched extensive training programs to implement good practices (Veterans Affairs 2002). The American Geriatrics Society developed guidelines for the management of persistent pain in older adults (American Geriatrics Society 1997). One study found that the use of a specific treatment plan for pain management, based on published guidelines, improved patients' pain outcomes. The study's Cancer Pain Algorithm addresses pain assessment and reassessment, along with decisions on analgesic drug choice. Its information package includes comprehensive side-effect protocols, equi-analgesic conversion charts, and a primer for intractable pain (Du Pen et al. 1999).
Two settings of care that may well have special importance in building good programs of care are nursing homes and managed-care organizations. Nursing homes already provide care for one-quarter of Medicare decedents, and some contend that this is likely to be half of all decedents by 2020 (Teno 2003; Brock and Foley 1998). Some nursing-home improvement projects have reported substantial gains (Tuch, Parrish, and Romer 2003), and Medicare's quality-improvement organizations have launched major collaborative quality-improvement projects on preventing pressure ulcers and pain. Palliative care seems likely to be a strong development in nursing facilities; a set of guidelines specifically drawn up for nursing facilities influences that work (Mezey et al. 2001).
Capitated health-care delivery is another locus of potential ferment and innovation. Teams like the Kaiser Bellflower team described earlier have documented substantial gains. Guidelines have been established to direct improvement activities as managed-care organizations focus upon end-of-life care (National Task Force on End-of-Life Care in Managed Care 1999).