The initiative to improve end-of-life care in the United States is taking center stage, and it is about time. The US population is aging, and the number of older Americans with comorbidities is growing. In addition, the US population is becoming more culturally diverse, so there is an increased need for more responsive, patient-centered care. Furthermore, the current healthcare system is disjointed, and contains elements that obstruct the delivery of high-quality end-of-life care, according to a new report.
In September 2014, the Institute of Medicine (IOM) released a consensus report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. The report, which comes nearly 17 years after the original end-of-life report, Approaching Death: Improving Care at the End of Life, discusses the current state of end-of-life care and makes recommendations for its improvement. The following are key findings and recommendations of the IOM committee (Table).
Call to Action The IOM committee emphasized that individuals nearing the end of life often experience high rates of preventable hospitalizations, which can fragment the delivery of care and create burdens for patients and families. “We have a fragmented, disjointed approach that results in people not getting what they want,” said David M. Walker, Cochair of the panel and former US Comptroller General, at a September 14, 2014, press briefing on the IOM initiative, which was held in Washington, DC.
In addition, although palliative care is associated with a higher quality of life, and may even prolong life in some patients, timely referral to palliative care is low.
In an effort to improve the delivery of care near the end of life, the IOM committee recommends that public health insurers, care delivery programs, and private health insurers cover the provision of comprehensive care for patients with an advanced illness, including cancer.
According to the IOM committee, comprehensive care should be patient-centered, family-oriented, and consistently accessible; encompass coordinated, efficient transfer of information across providers and settings; and align with individuals’ values and goals.
Clinician–Patient Communication and Advance Care Planning Patients should have the right to decide how their health is handled, especially as they approach the end of life. However, most people at that stage are physically, cognitively, and/or mentally impaired, and may not be able to adequately express their wishes. Consequently, these individuals often receive acute care by default, even if they prefer to receive palliative care. Clinician–patient communication and advance care planning are essential for protecting patients from receiving unwanted treatment.
The IOM report emphasizes the importance of developing standards for clinician–patient communication. In addition, payers and healthcare delivery systems should adopt these standards and should integrate them into assessments, care plans, and the reporting of healthcare quality.
Furthermore, clinician–patient discussions about advance care planning should be revisited through the continuum of patients’ care, because preferences may change over time. “Right now, there is too much fear and apprehension, and the discussions don’t happen,” said Philip A. Pizzo, MD, the other cochair of the panel and a former dean of Stanford University School of Medicine, at the press briefing. “What we call for is that there be an opportunity for discussions with clinicians throughout the life cycle and not just one time,” Dr Pizzo said. “It’s part of the process of living.”
Professional Development With regard to professional education and development, the report identifies 3 areas that leave room for improvement, including (1) insufficient attention to palliative care in medical and nursing school curricula, (2) educational silos that impede the development of interprofessional teams, and (3) deficits in equipping physicians with sufficient communication skills.
The importance of educating clinicians and other stakeholders about palliative care cannot be overstated. To stay abreast of trends in palliative care and to deliver optimal palliative care to patients, the IOM committee recommends that educational institutions, credentialing bodies, accrediting boards, state regulatory agencies, and healthcare delivery organizations establish training, certification, and/or licensure requirements for all clinicians who care for patients with advanced serious illnesses.
Policies and Payment Systems An untimely referral to hospice care may increase healthcare costs. For example, the current Medicare fee-for-service payment model incentivizes physicians for the quantity of services they provide to patients. In turn, this often results in an increase in the use of acute services, more transitions among care settings, and late enrollment in hospice care, all of which may reduce the quality of end-of-life care and increase its costs; in its report, the IOM committee stresses that palliative care can lower healthcare costs by reducing the use of acute care services.
To help reduce the avoidable use of acute services and to better honor individuals’ wishes, the IOM committee recommends that payment and healthcare delivery systems provide financial incentives for (1) medical and social support services that decrease the need for emergency department and acute care services, (2) the coordination of care across settings and providers, and (3) advance care planning. In addition, the IOM committee emphasizes the importance of electronic health records for communicating advance care plans across time, settings, and providers.
Public Education and Engagement Most Americans are not cognizant of advance care planning, and health community leaders are not doing enough to spread the knowledge.
To raise awareness and to educate the public about end-of-life care, the IOM committee recommends that public health and governmental agencies, community-based organizations, healthcare delivery organizations, and payers, among others, encourage the use of advance care planning by utilizing media, prepared educational material, evidence-based information about care options, and dialogue among individuals, their families, and their physicians.
