Question

Should the U.S. focus health policies on prevention of health care or the treatment of patients who already have disease? What are the pros and cons of each, of having a policy geared toward prevention versus having one geared toward rescue/treatment?

Answer 1

Ans) Desirable and obtainable care for those approaching death is determined by both individual and system characteristics and their interactions.

- The individual's disease, clinical status, emotional state, and preferences determine much about what clinical care is appropriate. Personal values, financial circumstances, family structure, and other patient or family characteristics set limits on what is possible or, at least, what is more or less difficult to accomplish.

- Over these individual conditions, clinicians and health care organizations typically superimpose a template or protocol that guides but need not rigidly dictate care. The nature of this template or protocol may, in turn, be partly determined by such factors as medical culture, locale (e.g., urban or rural), supply of health care resources (e.g., hospital beds, physicians, organized hospices), delivery system integration, organizational mission and leadership, community norms, statutory requirements, research linking processes of care with outcomes, and internal and external mechanisms for monitoring and improving the quality and outcomes of care. The committee believes that many problems with care at the end of life reflect disincentives for good care and that strategies to improve care will need to focus on change at the system rather than the individual level.

- In reaction against medical and technological overreaching, efforts to improve care systems for the dying share certain emphases with more general efforts to make health care more patient-centered and more concerned about patients' quality of life, not just their physiology. Although it is very much concerned with systems of care, the patient-centered care perspective tends to emphasize what is desirable and appropriate for the individual patient. Quality improvement strategies tend to be more population-oriented in their emphasis on institutional goals, priority setting, and statistical analyses. Both have emerged in an environment even more strikingly characterized by efforts to cut the cost of health care under the rubric of managed care.

- Overall, patient-centered, quality-improving, and cost-driven strategies for care of those with advanced or terminal illnesses may complement each other; they also may conflict.