AMA educates physicians on end-of-life issues

The American Medical Association in Chicago has launched two initiatives to better prepare physicians to help patients with life-threatening illnesses. The first, Elements of Quality Care for Patients in the Last Phase of Life, is a list of eight principles patients facing death should expect from health care providers and the community. The initiatives are part of the Education for Physicians on End-of-life Care project (EPEC). (For details on EPEC, see Medical Ethics Advisor, September 1997, p. 110.)

The second initiative supports the first by providing a comprehensive educational program for physicians on end-of-life issues. The goal of EPEC is to use a train-the-trainer format to reach all practicing physicians throughout the country within two years, says Linda Emanuel, MD, PhD, the AMA's vice president for ethics.

EPEC will be unveiled this month at a conference for hospital CEOs, managed care executives, and physician leaders, followed by a series of four two-day workshops in Chicago, Boston, Phoenix, and Atlanta. Topics will include how to conduct effective advanced care planning discussions, manage a new diagnosis of terminal illness, assess the common symptoms of terminal conditions, make decisions about life-sustaining treatment, manage imminent dying and aftercare, handle prognostic uncertainty, and respond to requests for physician-assisted suicide.

"We are setting a standard for what constitutes good patient care," she says. "Furthermore, this educates patients as to the quality of care they can rightfully expect when faced with death."

The AMA's eight principles are:

1. The opportunity to discuss and plan for end-of-life care. This should include the opportunity to discuss scenarios and treatment preferences with the physician and health care proxy, the chance for discussion with others, the chance to make a formal "living will" and proxy designation, and assistance with filling these documents in such a way that they are likely to be available and useful when needed.

2. Trustworthy assurance that physical and mental suffering will be carefully attended to and comfort measures intently secured. Physicians should be skilled in the detection and management of terminal symptoms (such as pain, fatigue, and depression) and able to obtain the assistance of specialty colleagues when needed.

3. Trustworthy assurance that preferences for withholding or withdrawing life-sustaining intervention will be honored. Whether the intervention is less complex (such as antibio t ics or artificial nutrition and hydration) or com - plex and more invasive (such as dialysis or mecha nical respiration), and whether the situation involves imminent or more distant dying, patients' preferences regarding withholding or withdrawing intervention should be honored in accordance with their legally and ethically established rights.

4. Trustworthy assurance that there will be no abandonment by the physician. Patients should be able to trust that their physician will continue to care for them when they are dying. If a physician must transfer the patient in order to provide quality care, that physician should make every reasonable effort to continue to visit the patient regularly, and institutional systems should try to accommodate this.

5. Trustworthy assurance that their dignity will be a priority. Patients should be treated in a dignified and respected manner at all times.

6. Trustworthy assurance that the burden to family and others will be minimized. Patients should be able to expect sufficient medical resources and community support, such as palliative care, hospice, or home care, so the burden of illness need not overwhelm caring relationships.

7. Attention to the dying person's goals. Patients should be able to trust that their personal goals will have reasonable priority, whether those goals are to communicate with family and friends, attend to spiritual needs, take one last trip, finish a major unfinished task in life, or die at home or another place of personal meaning.

8. Trustworthy assurance that care providers will assist the bereaved through early stages of mourning and adjustment. Patients and their loved ones should be able to trust that some support continues after bereavement. This may be by supportive gestures, such as a bereavement letter, and by appropriate attention to/referral for care of the increased physical and mental health needs that occur among the recently widowed.