Go Gentle into That Good Night The Past, Present, and Future of End-of-Life Care

End-of-life care has received increasing attention in recent years as the baby boomers age and health care costs continue to rise. This attention has brought with it remarkable growth in the field and improvement in care, but there remains work to be done in order to more consistently deliver high quality, compassionate, and patient- and family-centered end-of-life care. In this dissertation, I examine the past, present, and future of end-of-life care in order to shed light on the most effective ways to organize and deliver it. In the first analysis, I describe changes in symptom prevalence in the last year of life from 1998 to 2010. I find that the many important and troubling end-of-life symptoms, including pain and depression, became more common over that time frame, and that no symptom became less common. These changes occurred at the same time national efforts were underway to improve end-of-life care, which calls into question the nature of these changes and highlights the need to reexamine aspects of the delivery of end-of-life care. In the second analysis, I review the current evidence for palliative health services interventions to identify the populations that are appropriate for palliative care and the interventions that are effective in improving patient and family quality of life and reducing health care use and costs. I find that there are a broad range of currently available interventions that span a variety of goals, settings, and providers; that certain types of interventions are more or less effective for certain quality of life outcomes; and that health care use and cost outcomes are poorly studied overall. Some of these results enhance the existing understanding of what makes for effective end-of-life care. This information can be used in designing end-of-life care programs and in organizing research priorities for the field. In the third analysis, I simulate how cost and quality of life outcomes could fare through 2040 if three of the most effective palliative health services interventions identified in the second analysis were implemented today. I find that all three interventions lower health care costs, reduce mortality, improve quality-adjusted life years, and reduce pain, depression, and activities of daily living dependencies. These results highlight the benefit to individuals and to society of implementing evidence-based approaches to end-of-life care.

Copyright - Copyright ProQuest, UMI Dissertations Publishing 2015 Last updated - 2015-08-28 First page - n/a

0351:Gerontology