Twenty years ago, a study involving more than 4,000 patients revealed substantial shortcomings in how U.S. hospitals care for the seriously ill. Known by the acronym SUPPORT, this 1995 study underscored the importance of palliative care, which seeks to improve the quality of life for patients with advanced illnesses. “Yet 20 years after SUPPORT”, write Yael Schenker, MD and Robert Arnold, MD in the October 2015 edition of JAMA, “little has changed for seriously ill patients”.
The state of palliative care is disappointing, but it’s probably not surprising. As Schenker and Arnold explain, “palliative care workforce shortages are significant”. Access remains uneven, and the need for palliative care continues to grow. In short, the traditional medical model of providing direct care to patients isn’t working. The solution that the authors recommend consists of “a broader focus on systems of care, measurement and accountability for palliative services, and national policy changes.”
Strategies for Improvement
To build stronger “systems of care”, Schenker and Arnold suggest quality improvement strategies that have improved outcomes with other healthcare challenges. For example, if the goal is to help patients make decisions about medical treatments, hospitals need to develop policies that promote these discussions between patients and their providers. Clinicians need to learn appropriate communication skills, and electronic health records must allow medical providers to document patient decisions.
Measurement and accountability are also critical. Fortunately, efforts are already underway. Examples include quality measures such as adequate pain control, rates of chemotherapy administered during the last two weeks of life, and documentation of advanced directives. Connecting these programs to a patient’s electronic health record is important, but Schenker and Arnold also recommend linking the data to what they call “physician quality incentives”.
Finally, the authors call for “national policy changes” such as increased National Institutes of Health (NIH) funding for palliative care research. Medicare reimbursements for patient-physician discussions about end-of-life preferences is a step in the right direction, but the road ahead is a long one. Although the majority of care for the seriously ill occurs outside of healthcare settings, calls for more federal funding could run into budgetary constraints. Which of the author’s recommendations seem the most achievable?
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