Position Statement on Care at the End of Life

Position Statement P97
Becomes Policy February 1997

Background

Care at the end of life is an important issue to members of the American Medical Directors Association (AMDA). As primary care physicians, we help patients and their families cope with the decisions and emotions surrounding the dying process. As medical directors, we are responsible for ensuring that facility policies regarding end of life issues honor the dignity and autonomy of individual residents and that the staff is educated in providing compassionate and effective care at the end of life.

Positions

AMDA fully supports the Patient Self Determination Act and encourages physicians to address advance directives with patients upon admission to the long term care facility. When a patient has no advance directive and is judged by the attending physician to lack decisional capacity on this issue, every effort should be made to identify an appropriate surrogate (in compliance with state law) to address issues of care at the end of life.

AMDA acknowledges that not all available treatments are beneficial in the course of a particular patient's care. After obtaining informed consent, AMDA supports withholding or withdrawing any medical intervention that the physician and patient or appropriate surrogate feel imposes a greater burden than benefit, even if the unintended result of such non-intervention or withdrawal may hasten the patient's death.

AMDA supports aggressive treatment toward relieving the pain, anxiety, depression, emotional isolation, and other physical symptoms that can accompany the dying process even if the unintended result of such treatment may hasten the patient's death. All of the resources available to the medical profession and the care team should be mobilized to provide comfort to dying patients, family members and friends.

AMDA opposes any physician involvement in assisted suicide or active euthanasia of any person regardless of age. AMDA members recognize that we are entrusted with the care of people who are vulnerable in terms of physical frailty and cognitive impairment. Our position recognizes that physician involvement in assisted suicide or active euthanasia would erode the trust vital to the doctor/patient relationship.

AMDA supports professional and public education, policy development and research that enhances the delivery of compassionate and effective care at the end of life.

The foregoing is a policy statement and does not constitute legal advice for medical directors and the facilities with which they are affiliated. Each facility and its medical directors should obtain independent counsel and advice in adopting policies regarding end of life issues and the implementation of such policies.

References: Physician Assistance in Dying

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American Medical Association. AMA position statement on physician assisted suicide.

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Wanzer SH, Federman DD, Adelstein SJ, et al. The physician's responsibility toward hopefully in patients. NEJM 1989;320:844-849.

Watts DT, Howell T, Priefer BA. Geriatricians' attitudes toward assisting suicide of dementia patients. JAGS 1992;40:879-885.

Watts DT, Howell T. Assisted suicide is not voluntary active euthanasia. JAGS 1992;40:1043-1046.

Wildes, KWM. Death: a persistent controversial state. Kennedy Institute of Ethics Journal 1996(6):378-381.

The above references served as background reading for formulating AMDA's policy on End of Life Care. They are not all-inclusive on the subject.