From: Christine K. Cassel and Kathleen M. Foley. “Principles for Care of Patients at the End of Life: An Emerging Consensus among the Specialties of Medicine,” Milbank Memorial Fund, December 1999, http://www.milbank.org/endoflife/index.html#core (accessed 10/30/99)

Core Principles for End of Life Care

Clinical policy of care at the end of life and the professional practice it guides should:

1. Respect the dignity of both patient and caregivers;
2. Be sensitive to and respectful of the patient's and family's wishes;
3. Use the most appropriate measures that are consistent with patient choices;
4. Encompass alleviation of pain and other physical symptoms;
5. Assess and manage psychological, social, and spiritual/religious problems;
6. Offer continuity (the patient should be able to continue to be cared for, if so desired, by his/her primary care and specialist providers);
7. Provide access to any therapy which may realistically be expected to improve the patient's quality of life, including alternative or nontraditional treatments;
8. Provide access to palliative care and hospice care;
9. Respect the right to refuse treatment;
10. Respect the physician's professional responsibility to discontinue some treatments when appropriate, with consideration for both patient and family preferences;
11. Promote clinical and evidencebased research on providing care at the end of life.

American Medical Association (AMA) Statement:

The AMA contends that...

Since people in the last phase of life seek peace and dignity, they should be able to expect these eight elements of care from physicians, health care institutions, and the community:

• The opportunity to discuss and plan for endoflife care;
• Trustworthy assurance that physical and mental suffering will be carefully attended to and comfort measures intently secured;
• Trustworthy assurance that preferences for withholding or withdrawing lifesustaining intervention will be honored;
• Trustworthy assurance that there will be no abandonment by physicians;
• Trustworthy assurance that dignity will be a priority;
• Trustworthy assurance that burden to family and others will be minimized;
• Attention to the personal goals of the dying person; and
• Trustworthy assurance that care providers will assist the bereaved through early stages of mourning and adjustment.

From: The American Medical Association, Eight "Elements of Quality Care for Patients in the Last Phase of Life"; subsequently published in the editorial "Caring to the End: Conscientious Endoflife Care Can Reduce Concerns about Care of the Terminally Ill," American Medical News (December 15, 1997).

American College of Physicians:

The American College of Physicians (ACP) agreed with Principles 1, 2, 3, and 11 as written, but reworded the other seven principles:

Principle 4: Make alleviation of pain and other physical symptoms a high priority.

Principle 5: Recognize that good care for the dying person requires quality medical care, but also entails services that are family and communitybased to address, for example, psychological, social, and spiritual/religious problems.

Principle 6: Make continuity of care a priority (for example, the patient should be able to continue to be cared for, if so desired, by his/her primary care and specialist providers).

Principle 7: Advocate access to therapies which are reasonably expected to improve the patient's quality of life and provide that patients who choose alternative and nontraditional treatments not be abandoned.

Principle 8: Advocate access to palliative care and hospice care.

Principle 9: Respect the patient's right to refuse treatment, as expressed by the patient or an authorized surrogate.

Principle 10: Respect the physician's professional judgment and recommendations, with consideration for both patient and family preferences.

The ACP also added the following principles:

Recognize that although medical care has a critical role to play in supporting patients (and families) at the end of life, dying is fundamentally a profoundly personal experience and part of the life cycle;

Encourage health care professionals to work within their care environment to help ensure the provision of quality care and accountability for performance.