Death and dying: management of patients with end-stage disease

The culture of nursing homes historically has been rehabilitative. This approach has been enforced by the Omnibus Budget Reconciliation Act (1987) regulations, which focus on "decline" as largely avoidable. With the passage of the Prospective Payment System, nursing homes have become increasingly a site of death. In the same way that no sharp transition exists between living and dying, no sharp transition exists between life-prolonging, disease-specific therapy and palliative therapy. Life-prolonging therapy can lead to symptoms that require palliation, and, in some instances, (e.g., end-stage heart failure) life-prolonging therapy and palliative therapy may be indistinguishable. Palliative care, with the control of symptoms, relief of suffering, and promotion of quality of life, is appropriate to all stages of disease, with an increasing proportion of palliative care relative to curative therapy as the disease progresses. The goals of symptom management and attention to potential sources of suffering in palliative care are components of quality end-of-life care and are discussed.