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Clinical Crossroads: An 88-Year-Old Woman Facing the End of Life-Reply

Joanne Lynn, MD
JAMA. 1997;278(12):978. doi:10.1001/jama.1997.03550120038021.
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In Reply.  —An ordinary dying person, an elderly woman with end-stage heart failure, cannot count on good care in our patchwork system. Our needs when dying of chronic disease in old age are mismatched with a service system bent on rescue. Each of these letters advocates the service approach of the author(s). Most likely, however, reform will require learning new arrangements that make good care routine. We need a few years of vigorous innovation and research, aiming to learn how to regularly ensure worthy living in that last phase of life. Otherwise, our inefficient and often ineffective system will soon be overwhelmed by the large number of baby boomers facing the end of life together. Dr Solomon may be correct that managed care offers opportunities for improvement, although the evidence to date is disheartening. The adjusted rate of mortality in Medicare managed care is only 63% of expected,1 whereas the Veterans


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