Journal of Palliative Medicine

Deficiencies in education about end-of-life care are widely recognized, both in the "formal" or structured curriculum, and in the "informal" curriculum (the culture in which students are immersed as they learn medicine). Numerous approaches to addressing these deficiencies have been identified. These approaches include developing palliative care leaders; improving curricula; creating standards and a process for certification of competence; creating and enhancing educational resources for end-of-life education; faculty development; growing palliative care clinical programs as venues for education; textbook revision; and creating palliative care fellowship training opportunities. Current efforts in these areas are reviewed, and barriers to their implementation are highlighted.

Physicians' use of the "medical futility" concept to override the treatment demands of patients or their family/surrogates is difficult to justify in principle. At the same time, patient demands for obviously futile treatments can conflict with physicians' professional obligation to do no harm to their patients. There is no clear general principle available to resolve this conflict between patient self-determination and physician autonomy; extended negotiation between patient or family/surrogates and physicians provides the only prospect for satisfactory resolution. Though such negotiation will not invariably succeed in reaching agreement, the legal system should ensure that each side has some practical measure of independent authority and power to exert against the other in order to maximize the likelihood that the negotiating process will be seriously engaged.

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.

To increase the number of people using hospice and the length of stay in hospices, the hospice movement needs more urgently to refocus its message than to make the benefit more attractive.

The last days of life for a substantial proportion of dying older adults are spent in nursing homes. Considering this, the provision of Medicare hospice care in nursing homes would appear to be an equitable use of Medicare expenditures as well as a valid investment in improving the quality of life for dying nursing home residents. However, government concerns regarding possible abuse of the hospice benefit in nursing homes, as well as suggestion that the payment for the benefit in nursing homes may be excessive, has perhaps slowed the adoption of hospice services into the nursing home setting. Currently, access to hospice care in nursing homes is inequitable across facilities, and across geographic areas. In nursing homes where hospice is available and present, however, recent research documents superior outcomes for residents enrolled in hospice, and perhaps for nonhospice residents. Still, more research is needed, particularly research focusing on the government costs associated with the provision of hospice care in nursing homes. If subsequent research continues to support the "added value" of hospice care in nursing homes and at the same or less total costs, the issue of foremost concern becomes how equitable access to Medicare hospice care in nursing homes can be achieved. Access may be increased to some extent by changing government policies, and conflicting regulations and interpretive guidelines, so they support and encourage the nursing home/hospice collaboration.

Large state-by-state variations exist in location of dying and level of aggressive treatment during the final phase of life. This paper describes Oregon's incremental gains toward improving advance planning for end-of-life care in a state with the lowest rate of in-hospital deaths. Action strategies have required data gathering and reporting, and coalition building with a focus on systems change. Also, public education through the news media has proved to be a vital component of Oregon's process of change. The impact of media coverage is complemented by continuing education for health professionals. Special efforts are still needed to improve access to the Physician's Orders for Life-Sustaining Treatment program (POLST) for some rural, minority, and pediatric populations and for persons living at home with a diagnosis other than cancer. However, with enough time, a sustained effort, and a broad coalition of partners, profound change is possible.

The delivery of palliative care can vary greatly between countries depending on socioeconomic conditions and cultural issues. The evolution and development of palliative care varies greatly and influences the development of palliative care models. Models of palliative care in three different countries are discussed and suggestions are made for the future development of palliative care in developing and developed countries.