Systems of care: future reform

Major new ideas and opportunities shape the direction of reform in serving those coming to the end of life. Framing the problems as arising from changing demographics and evaluation of how we envision categories seems better than past ways of framing the issues. Another useful strategy is to build programs around three trajectories of the time course of disability while dying: a confined period of rapidly progressive disability and symptoms; intermittent exacerbations against the background of substantial organ system failure; and extreme multifactorial frailty. Finally, reform requires quality improvement, restructuring, and changes in Medicare payment.