The Supreme Court speaks--not assisted suicide but a constitutional right to palliative care. --Robert A. Burt, J.D.
 
The above is the title of an editorial published in the New England Journal of Medicine in 1997, after the U.S. Supreme Court ruled on their debate of physician-assisted suicide. [N Eng J Med. 1997 Oct 23;337(17):1234-6.] Judge Burt also stated that "A Court majority effectively required all states to ensure that their laws do not obstruct the provision of adequate palliative care, especially for the alleviation of pain and other physical symptoms of people facing death." His final remarks in this editorial were "A Supreme Court majority has thus provided an unexpected but strong and very welcome directive requiring states to remove the barriers that their laws and policies impose on the availability of palliative care." [Not only should palliative care be a constitutional right for all U.S. citizens, it should also be a human right for all people in the world.]

"Nurses thought that their nursing education had not adequately prepared them to provide end-of-life care and that they often learned 'the hard way."--Renea L. Beckstrand, RN, PhD, CCRN, Lynn Clark Callister, RN, PhD, and Karin T. Kirchhoff, RN, PhD
 
The above statement is from the landmark survey study article "Providing a "good death": critical care nurses' suggestions for improving end-of-life care." [ Am J Crit Care. 2006 Jan;15(1):38-45; quiz 46 PubMed]  For this survey of critical care nurses across the USA, the study revealed that "Of the 861 nurses who returned completed questionnaires during the course of 3 mailings (a response rate of 61% for the main study), 485 (56%) offered 1 or more suggestions in response to an openended question about how they would change end-of-life care in ICUs." Some of the remarks of the study included that "...all members of the healthcare team should receive education on end-of-life care." The study also found that ..."experienced nurses did not think that good deaths were routinely possible while patients were in an ICU. Many deaths nurses have witnessed in ICUs were less than ideal because of inherent problems with the intensive care environment (created to save lives), the lack of sufficient time for nurses to care for dying patients and the patients’ families, problems with communication between physicians and patients’ family members, the lack of appropriate education for physicians and nurses, and problems of keeping patients comfortable and following the patients’ wishes."
 
"...in order to ensure that all persons with serious illness and their families receive the quality of care they deserve, palliative care must become a routine and integral part of the U.S. health care landscape." --R. Sean Morrison, MD
 
Doctor R. Sean Morrison, stated in an editorial "Bringing palliative care to scale in our nation's medical schools."[J Palliat Med. 2010;13(3):233-34. PubMed]that "Whereas there is 1 cardiologist for 71 persons experiencing a myocardial infarction and 1 oncologist for every 141 patients diagnosed with cancer, there is only 1 palliative medicine physicians for every 31,000 persons living with a serious and life-threatening illness." 
 
Numerous years of work among countless investigators and millions of dollars have been allocated to study end-of-life (EOL) health care topics, which have identified many common problems. In 1995, a landmark article titled "A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments SUPPORT)." [JAMA. 1995 Nov 22-29;274(20):1591-8.PubMed] was published in the Journal of the American Medical Association (JAMA). The SUPPORT was a $29 million multi-center prospective observational two year study involving over 9,100 patients within 5 major medical centers. The intent of the study was to identify problems in life support practices within intensive care units (ICUs) within the United States. In summary, SUPPORT reported the following...
 
There were identified "Shortcomings in communication, frequency of aggressive treatment, and the characteristics of hospital death: only 47% of physicians knew when their patients preferred to avoid CPR: 46% of do-not-resuscitate (DNR) orders were written within 2 days of death; 38% of patients who died spent at least 10 days in an intensive care unit (ICU). and about half of patients who died in the ICU experienced moderate or severe pain and other symptoms in the last days of life."
 
[Too little has changed in the 15-years since SUPPORT. Most people still die within a hospital and most hospitals do not actively provide a palliative life care service.]

"When the end of life makes its inevitable appearance, people should be able to expect reliable, humane, and effective caregiving. Yet too many dying people suffer unnecessarily." --Marilyn J. Field, MD and Christine K. Cassel, MD
 
The above is a statement from the Committee on Care at the End of Life, which published a comprehensive report called "Approaching Death: Improving Care at the End of Life." [This was a 1997 Institute of Medicine (IOM) funded investigation in to how terminal health care is provided in the USA, as well as recommendations to improve care of the dying. And alhough this report was released 13 years ago, many of the problems identified by this investigation still remain--since the underlying problem remains. That is, very few health care workers have any formal knowledge or skill in providing palliative care. The IOM did recommend palliative care consultation become implemented, but even that recommendation is highly deficient.]
 
On The National Academies Press website, the following description is provided about this 456 page report (which can be purchased there).
 

• "Approaching Death reflects a wide-ranging effort to understand what we know about care at the end of life, what we have yet to learn, and what we know but do not adequately apply. It seeks to build understanding of what constitutes good care for the dying and offers recommendations to decision makers that address specific barriers to achieving good care."
• This volume offers a profile of when, where, and how Americans die. It examines the dimensions of caring at the end of life:
• Determining diagnosis and prognosis and communicating these to patient and family.
• Establishing clinical and personal goals.
• Matching physical, psychological, spiritual, and practical care strategies to the patient's values and circumstances. Approaching Death considers the dying experience in hospitals, nursing homes, and other settings and the role of interdisciplinary teams and managed care. It offers perspectives on quality measurement and improvement, the role of practice guidelines, cost concerns, and legal issues such as assisted suicide. The book proposes how health professionals can become better prepared to care well for those who are dying and to understand that these are not patients for whom "nothing can be done."

 
 
A recent article titled "Preliminary report of the integration of a palliative care team into an intensive care unit,"[Palliative Medicine. 2010;24(2):154-165.PubMed.] was published in Palliative Medicine by a group of physicians from New York, who noted that "Nearly half of all Americans who die in hospitals spend time in the intensive care unit in the last 3 days of life."  In their introduction of the article, the author's state that "The last phase of life is often accompanied by significant emotional and financial burden and inadequate support for patients and families. In the United States a report by the Hastings Center and the National Hospice Work Group revealed that for most Americans the healthcare experience in the last months of life is ‘deplorable and in need of full reconstitution’."
 
 
In a letter by Rachel S. Bensen, MPH & Thomas Bojko, MD, titled "To be or not to be (in the intensive care unit)--is that a question?"  [Crit Care Med. 2007 Feb;35(2):647-8. PubMed] they remarked that "In the United States, critical care medicine is playing an increasingly prominent role in acute care hospitals. Although the total number of hospital beds declined by 26.4% between 1985 and 2000, the number of critical care beds increased by 26% from 69,300 to 87,000, increasing the proportion of inpatient care provided in a critical care setting from 7.8% to 13.4%. More than 4 million patients are admitted to an intensive care unit (ICU) annually, generating costs of $55 billion." 
 
An astounding new article titled "ICU nurses experiences in providing terminal care," [Crit Care Nurs Q. 2010 Jul-Sep;33(3):273-8. PubMed] which was written by Dr. Laura Espinosa, et al. was just published.  [There are many remarkable statements made in the article that demonstrates how terminal ICU care is often practiced in the USA. Although involving only 18-ICU nurses at one 900 bed teaching hospital, it typifies some of the common problems that still persist in many ICUs in the USA. It is the teaching hospitals like this were you should expect to find the most contemporary and cutting-edge practices.]
 
First off, this group of doctorate nurse investigators' noted that "In the United States, approximately 2.5 million people die each year, with over 60% of these deaths occurring in hospitals, with half of those deaths involving ICU care. A retrospective study reported that 1 in 5 Americans died using ICU services. Moreover, recent studies indicate that the majority of these ICU deaths involved withholding or withdrawing life-sustaining treatments. Complicating matters, the decision to withhold or withdraw life support has dramatically increased, from 51% of all ICU deaths in 1987 to 90% in 1993."  Another important statement they made is that "The primary goal of aggressive care in the ICU is to stabilize and restore patients to their prior state of health. However, an increasing number of patients are receiving terminal care in ICU settings, contrary to the original intent of an ICU." They further accurately pointed out that "As the number of ICU deaths increase, ICU nurses more frequently act as frontline care providers for dying patients. Notwithstanding these trends, terminal care is not typically included in nursing curricula and is discussed in only 2% of nursing texts." 
 
These investigators found that there are three major themes in ICU nurses' experiences with terminal care: "(1.) Barriers to optimal care, (2.) internal conflict, and (3.) coping. From those themes, the defined barriers were "(1) lack of involvement in the plan of care, (2) differences between the medical and nursing practice models, (3) disagreement among physicians and other healthcare team members, (4) perception of futile care and unnecessary suffering, (5) unrealistic expectations of the family, and (6) lack of experience and education of the nurse."
 
They provided an example of the 'Lack of involvement in planning care' with a statement by a nurse who said "All we are doing is prolonging the inevitable for this person and family but we don’t have control over that and so that’s very difficult, it’s very difficult to not be a part of that decision or discussion process with the physicians. It’s not very often that they’ll [physicians] come to the bedside nurse and say, “What do you think is going on here?” And we’re the one that’s standing there. You know, 12 hours a day, and they come by and interact in little snippets." In the section for 'Differences between the medical and nursing models', a nurse remarked that "I get mad sometimes when they [physicians] kind of like tap dance around the whole thing and like, oh, they’re [only] looking at this much. It looks like the patient is getting better. The CBC went up a notch; he’s getting better. It’s like the chemistry is—the creatinine is—it’s a little better. And the family latches on to that like—like a thread—to hold on to anything." This is what happens too often because physicians can become focused upon numbers rather than the the patient. For the 'Disagreement among physicians' findings, they shared remarks from a nurse who stated that "I find that the families aren’t well informed by the physicians. . . .they’re given a lot of false hope. . . . And, understandably, the physicians want to make everybody better. . . .but some give a lot of false hope. And you feel bad. I mean I have a patient tonight who will never get off dialysis we just started. And she said, “Oh, he’ll be fine.” The family just doesn’t understand yet. And I don’t think the education is there. They [families] look at the nurses as knowing everything." For the findings of 'Perception of futile or unnecessary care' a nurse stated "And then you also feel like, why are they doing this? They’re going to be billing these families thousands and thousands of dollars that they probably don’t have. And there’s no—the prognosis is death. There’s no way this patient is going to pull out of this. I mean there’s never been one patient that’s ever survived." For the example of 'Unrealistic expectations of the family', they shared the remarks of an ICU nurse who stated "It was horrible because he’s a very large guy, and we coded him and he’s keeping going on and off, on and off. I left and they coded him six more times, and he ended up dying about 11:23 last night. But they didn’t want to give up. The son said, “I cannot live with it if you just extubate him and let him go.” So they wanted us to do everything, and he was hemorrhaging from his lung. It was pretty bad. Blood was just pouring from the tube, we kept pumping on his chest, it was really very traumatic. It was a bad situation." In their discussion part of the article, the authors' discussed how research has shown that "Interestingly, critical care nurses reported more occupational stress, showed higher burnout rates, and experienced greater death anxiety than did hospice nurses." One of the concluding remarks in this article was "Nurses in the present study indicated that better education about terminal care, staff support, and better communication would improve care to dying patients and their families."  

 
..."the medical culture has come to equate the finality of death with the ultimate failure—a detrimental view that precludes acceptance of palliative care services into most intensive care settings."--Carrie A. Bennett, MS, CNS-BC [Am J Nurs. 2010 Apr;110(4):72. PubMed]
 

• Chronic Critical Illness

 
One big population of patients that could benefit greatly from palliative care are those with "chronic critical illness." A recent landmark article By Judith E. Nelson, MD, JD et. al, titled "Concise clinical review: Chronic critical illness" [Am J Resp Crit Care Med. 2010;may 6. PubMed] was published in the American Journal of Respiratory and Critical Care Medicine. The article noted that "Recent estimates indicate that there are more than 100,000 such patients in the United States at any point in time, and increasing numbers in some other countries. Chronic critical illness is a devastating condition for patients and their families and, at a cost exceeding $20 billion each year, for the US healthcare system as a whole." These are "patients who survived an initial episode of critical illness but remained dependent on intensive care, neither dying in the acute period of ICU treatment nor recovering." Furthermore, they stated that the hallmark of these patients is "...respiratory failure requiring prolonged dependence on mechanical ventilation." and..."Nearly all patients with chronic critical illness leave the hospital with profound impairments of physical function, cognitive status, or both, and most therefore require institutional care. Hospital readmission rates during the year after hospital discharge exceed 40%. Patients discharged to extended care facilities who cannot be sufficiently rehabilitated for return to home by six months usually remain institutionalized until death. Across multiple studies, fewer than 12% of chronically critically ill patients were alive and independent one year after their acute illness." Put another way, these patients have a one year mortality of 88%, and "Although the chronically critically ill account for fewer than 10%, they consume between 20% and 40% of ICU bed days and other critical resources." [Since functional limitations are common, even patients who recover sufficiently to permit discharge from an in-patient facility typically require paid caregiving as outpatients or family members must leave jobs to provide ongoing care. The overall cost to the healthcare system for the management of chronic critical illness already exceeds an estimated $20 billion per year and is expected to climb with increases in the incidence of this syndrome and in overall expenditures for critical care, which nearly doubled between 1985 and 2000 and represent 13% of all hospital costs in the US. As far as costs, even though these patients are living in the last year of life], "A cost-effectiveness analysis calculated that providing prolonged mechanical ventilation to Medicare-eligible patients with multiple co-morbid conditions exceeds $200,000 for each quality-adjusted life year gained, as compared to patients who had life-sustaining therapies withdrawn before day 14 of mechanical ventilation." The reason for the high cost of LTACs is probably because "Reports by individual LTACs suggest that patients are being transferred from acute hospitals earlier in the course of critical illness, with higher degrees of illness severity. If these trends of earlier transfer to LTACs continue, the cost savings associated with care in such facilities may be offset by an increase in rates of subsequent readmissions to acute hospital." It was also pointed out that "Effective and efficient care can be provided to the chronically critically ill outside of the ICU, either in specialized in-hospital units or free-standing facilities, with lower levels of nursing intensity, technology and ancillary care." And what they are probably referring to is palliative care units and facilities, which they discussed and noted that "Palliative care is an essential component of comprehensive treatment for all chronically critically ill patients, including those receiving life-prolonging therapies. This care includes sensitive, effective, proactive, and ongoing communication with patients and families about prognosis, achievable goals of treatment, and alternatives to continuation of critical care."
 
[As noted above, the impact upon family members of chronic critically ill patients is quite burdensome and there is a high rate of their depression. A group of investigators studied the symptoms that family members experience when a loved one is at a high risk for dying.] In their article titled "Symptom experiences of family members of intensive care unit patients at high risk for dying" [Crit Care Med. 2010 Apr;38(4):1078-85. PubMed] the investigators' wrote that "We found that a significant proportion of family members had substantial symptoms of traumatic stress (56.8%), anxiety (79.7%), and depression (70.3%) 3 to 5 days after the patient’s admission to the ICU. Our findings corroborate those of investigators outside the US who documented high levels of traumatic stress and anxiety in family members." They also stated that "Recent evidence suggests that high levels of posttraumatic stress disorder (PTSD) symptoms are common in family members of intensive care unit (ICU) patients approximately 3 months after ICU discharge." Tilden and Thompson also discussed the financial burden in their article "Policy issues in end-of-life care" [J Prof Nurs. 2009 Nov-Dec;25(6):363-8. PubMed] by stating that "The financial costs to family caregivers of caregiving at end-of-life are rarely tallied. Economic needs of patients have been associated with caregivers' lost jobs, lost savings, bankruptcy, reports of depression, and thoughts about limiting medical treatment as a cost-cutting measure. In studies with very large samples of patients with health insurance for all but a tiny fraction, families experienced significant financial burden associated with lost savings, lost work, second mortgages, and high out-of-pocket costs for medications, medical transportation, paid help, and special beds and other equipment."
  
[Chronic critically ill patients provide a very lucrative business for the ever expanding LTAC facility industry and acute care hospitals.] As noted in another landmark article titled "Long term acute care hospital utilization after critical illness," [JAMA. 2010 Jun 9;303(22):2253-9. PubMed] the authors pointed out that "The number of these hospitals doubled, and critical care hospitalizations ending in long term acute care transfer and long term acute care−related costs more than tripled during the 10-year study period." In their opening statement of the article, it was noted that "Approximately10% to 20% of patients recovering from critical illness experience persistent organ failures necessitating complex care for a prolonged period of time." They also pointed out that "One-year mortality was poor, ranging from 48.2% to 52.2% over the study period." [Indeed, these patients have morbidity and mortality that is similar to cancer, as well as living in their last year of life, which is why they should be primarily managed by palliative care--not heroic and costly critical care.]
 
[Too many of these people who living in the last year of life end up in an ICU and are then put on a ventilator and then get a permanent feeding tube, a tracheostomy breathing tube, and a central intravenous line before being discharged to a long-term facility (i.e., if they are one of the "lucky" one's who survive). Short-term acute care facilities need to get patients out of the hospital early if they are going to make a profit. In order to do that, it is presumed that the next facility will wean the ventilator and maybe provide some rehabilitation.] The wean off of mechanical ventilation is often not successful, as was pointed out that "Many patients transferred to long-term acute care hospitals for ventilator weaning are not successfully weaned from respiratory support, and either become ventilator dependent or die in the acute care setting. Yet data suggest that patients, families, and physicians may not fully understand the extent of the poor prognosis of this population." [JAMA. 2010 Jun 9;303(22):2253-9. PubMed] A final very important statement in this article was "Despite this substantial increase in long-term acute care utilization over the years, there is surprisingly little clinical evidence in support of long-term acute care hospitals as a model of care for patients recovering from critical illness."
 
[Of course a much better option would be for these vast populations of patients to be transferred to a palliative care center where their final days of life would provide optimal comfort care and quality of life. With appropriate funding and reimbursement for palliative care services, all of the long-term care facilities could be converted to palliative care facilities where more humane and sensible care would be provided. Furthermore, it would close the revolving door that these "ICU survivors" commonly get stuck within, and then bounce back and forth between a hospital intensive care and the long-term care facility, while living out the last months, weeks, or days of life. Staff in acute care facilities refer to these patients as "frequent fliers" and come to recognize them by name or face.]
  
For further reading and help with chronic critical illness topics, there is a wonderful website on the Internet developed by the Society of Critical Care Medicine that has brochures about CCI and other related topics.
 

• Prognosis Prognostication

 
[Prognosis and outcome is typically not [realistically] discussed because there is often a perceived urgency to "hurry up and rescue while there is still a chance." When distressed family members are asked the proverbial "do you want us to do everything," physicians usually do not lengthy discuss or emphasize long-term outcomes that likely will entail profound and permanent disability requiring comprehensive care and total bed rest for the remaining time of life.] In a recent study by White et. al, published in an article titled "The language of prognostication in intensive care units" [Med Decis Making. 2010 Jan-Feb;30(1):76-83. PubMed] a statement was made that "We found considerable variability in the language physicians use to disclose prognosis. Few physicians used numbers to convey the prognosis, instead opting for qualitative probability statements and/or a wide variety of nonprobabilistic statements. Physicians seldom checked whether family members wanted to discuss prognosis or whether they understood the prognostic information provided."  
  
In a recent and novel study by by El-Jawahri, et. al, investigators used either verbal discussion or a video to convey or depict what is commonly entailed in end-of-life practice to help facilitate end-of-life discussions with patients and loved ones. The study article is titled "Use of video to facilitate end-of-life discussions with patients with cancer: a randomized controlled trial." [Clin Oncol. 2010 Jan 10;28(2):305-10. PubMed] Patients' were randomized to hear a verbal discussion or a video and "The video depicts three levels of medical care: life-prolonging care (cardiopulmonary resuscitation [CPR], ventilation), basic care (hospitalization, no CPR), and comfort care (symptom relief)." Their design consisted of "Fifty participants were randomly assigned to either the verbal narrative (n 27) or video (n 23). After the verbal description, 25.9% of participants preferred life-prolonging care, 51.9% basic care, and 22.2% comfort care. In the video arm, no participants preferred life-prolonging care, 4.4% preferred basic care, 91.3% preferred comfort care, and 4.4% were uncertain (P .0001)." In similar work by Volandes, et. al, a video was used to discuss end-of-life treatment with patients and loved one's. In their article titled "Improving decision making at the end of life with video images," [Med Decis Making. 2010 Jan-Feb;30(1):29-34. PubMed] they reported that "Our video decision aid improved end-of-life decision making by decreasing uncertainty regarding subjects’ preferences, especially for those with limited literacy." The authors studied this method because "The medium of video allows patients to envision health states in a manner not easily captured with verbal communication and can both engage people and efficiently communicate information about the experience of illness." The videos can be purchased online at a website called Advanced Care Planning.
 
[Similar types of tutorial videos would also be very useful on YouTube so that lay-people could view them for free. YouTube now has many academic and scholarly tutorial videos. Another important thing that would really help educate the general public would be a documentary video about life support and end-of-life healthcare practice. Of course, it would probably be classified as a horror movie and most people do not like to see scary movies.]
Another method of helping to prognosticate those who have a life-limiting illness is with a tool called "CARING." Fischer et. al described the use of CARING in their article "A practice to identify patients who may benefit from a palliative approach: The CARING criteria." [J Pain Symptom Manage. 2006 Apr;31(4):285-92. PubMed] These investigators used their CARING tool on 873 patients and found that "A simple set of clinically relevant criteria applied at the time of hospital admission can identify seriously ill persons who have a high likelihood of death in 1 year and, therefore, may benefit the most from incorporating palliative measures into the plan of care." [Although there is no universal prognostic tool for every discipline, most experienced physicians have seen the same similar patients so many times that they can provide a pretty accurate prognosis--which is not always desired or believed by patients and/or family members.]
 
"Most troubling is the fact that regions of the country where more life-extending services are given and more Medicare dollars are spent show worse patient outcomes."--Virginia P. Tilden, RN, DNSc, FAAN & Sarah Thompson, RN, PHD
 
The above statement was from an article titled "Policy issues in end-of-life care." [J Prof Nurs 2009 Nov-Dec;25(6):363-8. PubMed] The author's provided a pretty good summary of problems in end-of-life care. Another statement was that “Rescue medicine” is the default mode in American hospitals, although 7 out of 10 deaths today result from life-limiting chronic illnesses that follow a slow and often predictable decline. The misalignment of aggressive-focused acute-care hospitals serving an aging and chronically ill population sometimes results in conflict among clinicians or between families and providers over deciding the best plan of care in intensive settings. Patients and families themselves sometimes demand aggressive life-extending treatments even when not medically advised. The overall momentum in tertiary care settings tends toward life extension. Further, although palliative care services have grown rapidly, less than half of hospitals offer them. Data from the American Hospital Association Survey of Hospitals show that more than 30% of approximately 4,000 hospitals that are appropriate for palliative care have a palliative care program (http://www.aha.org/aha/research- and trends/chartbook/2007chartbook.html; American Hospital Association, 2007)." [It could also be pointed out that, even most of those that do offer palliative care, the program is too weak and under-funded to provide suitable service.]
  
[For the small percentage of patients who do go home, instead of being put into "greener pastures" for their final days of life, family members are taught to perform all of the care, or at least help with their comprehensive care. The care is very demanding and often quite extensive. Home care for ICU "survivors" often includes mechanical ventilator monitoring, tracheostomy care, airway suctioning, artificial feedings, bathing, wound(s) care, diaper, linen and clothing changes, breathing treatments, central line care, drug administration, vital sign monitoring, occupational therapy, and more. It usually takes more than one family member to perform care 24/7, or else a visiting or live-in caregiver is hired. There is a great deal of sleep disturbance for family members who are awakened to assist with care, or a crying voice or a monitor alarm disturbs them. These patients also require frequent visits to [distant clinics] for follow-up exams and repeat tests. The financial burden is also quite heavy. Approximately 84% of family caregivers routinely have to leave their job or end their career to provide home care. It is not much less of a burden for those who are put into an LTAC facility because they are often miles from the family home and there is a compelling desire to visit their loved one daily or regularly. The care within these facilities is often more frugal than acute care hospitals, since the primary objective is usually to make as much profit as possible. The staff in the facilities is paid less and number less, etc. One compelling reason for regular visiting a loved one in a LTAC facility is to assure that they are being treated appropriately.] 
  
In an article by Margaret L. Campbell, PhD, RN, FAAN, titled "Palliative care consultation in the intensive care unit" [Crit Care Med 2006 Nov;34(11 Suppl):S355-8. PubMed] it was pointed out that "When the ICU interventions fail to restore the patient to a prehospital functional baseline or to a desirable existence, palliative care considerations, which may have been used concurrently, replace curative/prolongation therapies. The patient’s death often occurs rapidly after the cessation of life supports, giving an appearance of sudden death even when the patient was approaching death before the attempt at rescue in the ICU. Thus, palliative care competencies need to be part of the ICU staff skill mix. However, nurses and physicians who practice in the ICU are largely trained in resuscitation and prolongation interventions, with little or no training in palliative care competencies. ...Although ICU staff face a large number of deaths, training in the care of dying patients may be limited."
 
[The problems with end-of-life care remain since the solutions offered are not adopted, or they are too weak, or not required by law. Proposed changes may also be too slow to become fully enacted.] For instance, in an article titled "Availability and integration of palliative care at US cancer centers"[J Clin Oncol. 2009 Jun 20;27(18):3052-8. Epub 2009 May 18. PubMed] it was stated that the American Society of Clinical Oncology "...has taken a step further to support full integration of palliative care as a routine part of comprehensive [cancer] care in the United States by 2020."
 
[A better goal would be to mandate palliative care to become available and actively practiced, by all disciplines, and in ALL health care facilities in the USA within 2-years. Palliative care should be co-practiced with all comprehensive care--not just some cancer care. Palliative care is as essential as curative care. Palliative care certification and bi-annual competencies should be a prerequisite for all health care workers (HCWs), just like CPR and advanced CPR courses. Colleges and universities must also start offering campus and Internet undergraduate and graduate courses that lead to degrees in palliative care medicine. One of the big obstacles is that there currently are no free educational materials and programs to teach palliative care to HCWs (and patients and families). There is plenty of books and programs available, but there are big fees required for everything.] For instance, there is a national training  program for nurses that is described in an article "End-of-life nursing education consortium for pediatric palliative care (ELNEC-PPC)," [MCN Am J Matern Child Nurs. 2007 Sep-Oct;32(5):298-302.PubMed] which provides the opportunity for nurses to attend an educational seminar that provides ten learning modules covering hospice and palliative care subjects.  The program began in 2000 and over 10,000 nurses in the USA have attended. Information about the can be found on the internet about the ELNEC. The one day course is $500. In another article about the ELNEC titled "Evaluation of palliative care nursing education seminars," [Eur J Oncol Nurs. 2010 Feb;14(1):74-9. PubMed] the authors stated that "...many nurses have received little or no education about palliative care. ...In order to improve the quality of life for those facing life-threatening illnesses around the world, ongoing support is needed for world-wide palliative care educational efforts."
 
Beside the ELNEC, there is also a National Board for Certification of Hospice and Palliative Nurses (NBCHPN) , which offers a candidate handbook and computer based examinations. The NBCHPN has certified over 16,000 nurses.
 
Palliative care is also a new sub-specialty for physicians, but too few medical schools currently offer or require the education and training. The EPEC project is described in an article titled "Assessment of the Education for Physicians on End-of-Life Care (EPEC)" [J Palliat Med 2004 Oct;7(5):637-45.PubMed], which has made some progress in voluntarily training physicians in palliative care. The project has been in existence since 1997. The EPEC has a website that offers internet learning courses and continuing education credit about palliative care--each for a fee.
 
[Courses in palliative care are somewhat costly and currently are an elective--not a requirement. This is wrong. There are over 2.9 million nurses and 954,000 physicians in the USA, as well as staff in many other disciplines. In the past decade, about 1% of nurses and 0.3% of physicians have received voluntary education and training in palliative care. The big reason for the relatively small percentage of progress is because of high costs for the education and there is no existing national legislation requiring palliative care certification.]
 
The latest Associated Press news report about problems in end-of-life care was written by Marilynn Marchione and titled "Americans are treated, and overtreated, to death." [Although most Americans may be shocked and outraged by this story, it is not the first bad report card about this serious widespread problem. Most health care workers will be un-phased by this latest news report.]