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RESEARCH BRIEFS Doctors Struggle with Complex Issues When a Patient Is Dying When doctors care for dying patients, there often is no easy way to define a "good" or "bad" or "typical" or "ideal" death. Interviews with 75 internists at a major academic medical center reveal instead an ambiguous and complex experience, report Mary-Jo Del Vecchio Good, HMS professor of social medicine, and her colleagues in the March 2004 Social Science & Medicine. Three major themes emerge from a qualitative analysis of physicians' narratives about the care of dying patients. Within this framework, the positive and negative characteristics can mix and vary in nuanced ways over the course of treatment. The researchers found nuanced mixtures of positive and negative characteristics, which may vary over the course of medical treatment (see table). "Physicians' stories are incredibly powerful," said Good, first author of the study. "These narratives are action tales of what doctors are doing and to whom they are relating--the family, the patient, the medical team--as they care for dying patients. They break down stereotypes about physicians' roles and the process of dying." "The study elucidates some of the reasons why it may be so hard to improve the care of dying patients," said principal investigator Susan Block, HMS associate professor of psychiatry at Brigham and Women's Hospital and the Dana-Farber Cancer Institute. "It's messy. It's complicated. Even something as basic as understanding whether a patient is dying is a difficult task." End-of-life care can pit a culture of high-technology medicine against the palliative care goals of comfortable and dignified final days. Doctors may accept that a patient is dying only when many interventions fail, explaining a tendency to overtreat patients. Or doctors may be frustrated by patients and family members who request highly aggressive and medically futile measures. "Part of this is an educational issue," said Block, who codirects the HMS Center for Palliative Care. "This study is helpful in illuminating the need for additional teaching about differences in the dying trajectories of patients with different kinds of diseases. It shows us the importance of giving physicians opportunities to speak about and process the ambiguities, which are very difficult." --Carol Cruzan Morton   HMOs May Improve Diabetes Care By Providing Home Monitors For people with diabetes, keeping a close watch on blood sugar levels can forestall complications and monitoring these levels at home has proven benefit. A study of more than 3,000 patients before and after their health maintenance organization provided free home glucose monitors and training has determined that HMOs could encourage home monitoring and improve care by offering the $100 measuring devices for free. To determine the effect of providing monitors, Stephen Soumerai, HMS professor of ambulatory care and prevention at Harvard Pilgrim Health Care, and his colleagues checked pharmacy records that tallied the number of glucose test strips dispensed and the frequency of refills of oral glucose-controlling medications. Both parameters increased after patients were given the monitors, and increased monitoring was associated with improved blood sugar levels for patients who had the poorest control of their blood sugar. Having doctors provide the blood sugar monitors at no charge to the patients has both economic and educational benefits, according to Soumerai. For some low-income patients, the cost of the machine is a barrier. For others, the contact with a health care professional who provides the monitor and explains how to use it reinforces the importance of controlling their sugar levels. "This is a very inexpensive intervention that can be undertaken by managed care organizations around the country and that can improve the quality of care of patients with diabetes," said Soumerai, lead author of the study, published in the March 22 Archives of Internal Medicine. The findings validate a growing trend among states to require insurers to cover all self-monitoring equipment and supplies for people with diabetes. --Pat McCaffrey