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Improving Palliative Care

Diane E. Meier, MD; R. Sean Morrison, MD; and Christine K. Cassel, MD
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From Mount Sinai School of Medicine, New York, New York. Acknowledgments: The authors thank several anonymous reviewers for helpful suggestions. This work was adapted from a paper presented at the Milbank Memorial Fund in October 1994. Grant Support: Drs. Meier and Morrison are recipients of an Open Society Institute Faculty Scholars Award of the Project on Death in America. Dr. Morrison is a Brookdale National Fellow. This work was also supported by grants from the United Hospital Fund, the Commonwealth Fund, the Mount Sinai Hospital Auxiliary Board, the Greenwall Foundation, the Kornfeld Foundation, and the Milbank Memorial Fund of New York City. Requests for Reprints: Diane E. Meier, MD, Box 1070, Mount Sinai Medical Center, New York, NY 10029. Current Author Addresses: Drs. Meier, Morrison, and Cassel: Box 1070, Mount Sinai Medical Center, New York, NY 10029.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;127(3):225-230. doi:10.7326/0003-4819-127-3-199708010-00008
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Although most deaths in the United States occur in hospitals, data suggest that hospitals and physicians are not equipped to handle the medical and psychosocial problems of dying patients.In this article, we review the barriers to achieving a peaceful death, including inadequate medical professional education on palliative care, and public and professional uncertainty about the difference between forgoing life-sustaining treatment and active euthanasia, and health professionals' difficulty recognizing when patients are dying and the associated sense that death is a professional failure. Other barriers include fiscal constraints on the length of stay, the number of nurses available to care for dying patients, legal and regulatory constraints on obtaining opioid prescriptions, and a segregated system of hospice care that requires patients to be separated from familiar health care providers and settings in order to receive palliative care at the end of life. Identifying the opportunities that can improve the delivery of palliative care at the end of life is the first step toward developing corrective approaches. Strategies that enhance these opportunities are proposed.

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