Edes Thomas, Shreve Scott, Casarett David
Department of Veterans Affairs, Veterans Health Administration, Office of Geriatrics and Extended Care, Washington, DC, USA.
J Am Geriatr Soc. 2007 Oct;55(10):1645-9. doi: 10.1111/j.1532-5415.2007.01321.x.
The pursuit of a "good death" remains out of reach for many despite numerous piecemeal solutions to address the growing need for access to quality care at the end of life. In 2002, U.S. veteran deaths were at an all-time high, few Department of Veterans Affairs (VA) hospitals had inpatient palliative care services, and there was no reliable approach to meet home hospice needs. The VA embarked on a course of major change to improve veterans' care at the end of life. A coordinated plan to increase access to hospice and palliative care services was established, addressing policy development, program and staff development, collaboration with community hospices, outcomes measurement, and proving value to the organization. To determine progress and monitor resource allocation, workload and outcome measures were established in all settings. Within 3 years, the number of veterans receiving VA-paid home hospice had tripled, all VA hospitals had a palliative care team, 42% of all veterans who died as VA inpatients received a palliative care consultation, and a nationwide network of VA partnerships with community hospice agencies was established. Through a multifaceted strategic plan and a mission of honoring veterans' preferences for care at the end of life, the VA has made rapid progress in improved access to palliative care services for inpatients and outpatients. The VA's experience serves as a powerful example of the magnitude of change possible in a complex health system and a model for improving access and quality of palliative care services in other health systems.
尽管有许多零散的解决方案来满足临终时对优质护理日益增长的需求，但对许多人来说，追求“善终”仍然遥不可及。2002年，美国退伍军人死亡人数创历史新高，很少有退伍军人事务部（VA）医院提供住院姑息治疗服务，而且没有可靠的方法来满足家庭临终关怀需求。VA开始了一项重大变革，以改善退伍军人的临终护理。制定了一项协调计划，以增加临终关怀和姑息治疗服务的可及性，涉及政策制定、项目和人员发展、与社区临终关怀机构的合作、结果评估以及向该组织证明价值。为了确定进展情况并监测资源分配，在所有环境中都制定了工作量和结果指标。在3年内，接受VA支付的家庭临终关怀服务的退伍军人数量增加了两倍，所有VA医院都有一个姑息治疗团队，42%在VA住院死亡的退伍军人接受了姑息治疗咨询，并且建立了一个全国性的VA与社区临终关怀机构合作的网络。通过一个多方面的战略计划以及尊重退伍军人临终护理偏好的使命，VA在改善住院患者和门诊患者获得姑息治疗服务方面取得了迅速进展。VA的经验有力地证明了在一个复杂的卫生系统中可能发生的变革规模，并且为其他卫生系统改善姑息治疗服务的可及性和质量提供了一个典范。
