Reforming the Care System to Support Those Coming to the End of Life

BACKGROUND: Health care has shifted its focus regarding dying patients toward improving care rather than striving for cure. METHODS: The Center to Improve Care of the Dying and the Institute for Healthcare Improvement sponsored a quality improvement collaborative from July 1997 through July 1998 to learn how to accomplish this. RESULTS: (1) Classifying persons as "dying" or "not dying" does not help to ensure quality care at the end of life. The impossibility of predicting time of death in many illnesses demands not only a shift to asking whether a patient is sick enough to die of the current illness, but also targeting special services to those patients. (2) Quality improvement strategies in this arena regularly yield important gains in such fields as pain control, bereavement support, and advance planning. (3) Serious reform probably must originate in system design and routine practice rather than in exhortations to customize decision making. The Study to Understand Prognoses and Preferences in Outcomes and Risks of Treatment (SUPPORT) found that 80% of the substantial variation in the rate of death at home correlated with hospital bed supply. CONCLUSIONS: Based on the inadequacy of the current classification system and on the unpredictability of the timing of death, a conceptual model is proposed for many patients that mixes conventional "aggressive" care with palliative care and is triggered by illness severity rather than by prognosis. High leverage reform in end-of-life care is available now through quality improvement strategies.