Table 2.
Examples of US programs oriented towards the 3 trajectories followed by patients at the end of life
| Programme | Trajectory | ||
|---|---|---|---|
| Rapid decline in function over a few weeks or months before death | Progressively compromised reserves with intermittent exacerbations and sudden death | Long term slow decline in function with frailty, dementia, or multiple chronic conditions | |
| Name | Project safe conduct14 | PhoenixCare15 | PACE (program of all-inclusive care for the elderly)16 |
| Design, year begun, patients served | Experimental, begun in 1998; continues to be offered for lung cancer patients at the cancer centre | Experimental, begun in 1998; now part of the Medicare coordinated care demonstration project for chronic conditions, in 15 sites with 14 000 patients | Experimental initially, begun in 1970; now a capitated Medicare benefit; currently, 35 programmes serve 17 000 patients throughout the US; continues to expand |
| Goals | To provide palliative care and life prolonging treatments | To reduce exacerbations and hospital admissions; to return control to patient and family; to allow patient and family to choose the site and situation of dying | To provide coordinated, community oriented supportive services, aimed at delaying or preventing placement in a nursing home |
| Population | Patients with advanced lung cancer | Patients with heart and lung failure with very limited reserve who have usually been admitted to hospital repeatedly | Age 55 or over; certified to need nursing home care; able to live safely in the community at time of enrolment |
| Intervention | Interdisciplinary palliative care and support from the time of diagnosis; family conferences and integration with cancer care | Optimal self management and home based case management incorporating palliative care and comprehensive advance care planning | Adult day care; coordinated medical care provided by PACE physician; capitated to include all other care |
| Evaluation | Evaluation before and after the intervention | Randomised trial | Observational study |
| Effects on the patient | Increased enrolment in hospices and longer length of stay | Improved functioning, self rated health, and symptoms; increased advanced care planning | High patient and family satisfaction; lower costs, less use of hospitals and nursing homes; higher numbers of deaths at home than the general elderly population |