Sick To Death > Chapter 4 > Opportunities and Challenges
Eventually, good care will require major changes in our culture - the way we structure reality, what facts we take to be salient, and the language we use. Indeed, I judge that most of these cultural changes are largely inevitable - what well-considered strategy can do is to accelerate the pace of change and avoid inept care and suffering for many as we undertake reforms.
This chapter lays out a number of approaches to the entrenched barriers I foreshadow above, as well as arguments for focusing upon caregivers and financing and high-leverage opportunities for change. Some of my claims will be controversial, not only to those who have not yet endorsed the need for substantial reforms in care for people in the last years of life but also among those who work in palliative care, long-term care, and elder services. A productive, ongoing public discussion would help shape and galvanize support for a useful agenda.
The prospects for social reforms always depend upon our specific situation - the challenges and opportunities that our particular history and situation engender. Reformers must create and implement strategic plans; it is always difficult to gauge whether any particular strategy might be suitable for implementation and what effects it would actually have. Very experienced and insightful strategists are often proven wrong. But by thinking through the situation, considering a range of alternative actions, and judging the likely course and effects of each, we can argue for putting efforts toward the highest-leverage actions rather than pursuing opportunities as they happen to come up.
I have become convinced that no individual patients or physicians and nurses - however beneficent their actions - can resolve the issues in care for the last phase of life. Of course, activated patients and skillful clinicians are going to do better than others; but the dysfunctions are so widespread and so intrinsic to the care arrangements that major reforms at the organizational or political levels will be essential.