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This series of published papers, developed by the End-of-Life
Care Consensus Panel, addresses a broad range of issues encountered
by physicians and patients as they grapple with end of life
Care at the End of Life: Guiding
Practice Where There Are No Easy AnswersBernard Lo, MD, FACP, Lois Snyder, JD, and Harold C. Sox, MD,
This paper launched a series of articles about end-of-life care
developed by the ACP-ASIM End-of-Life Care Consensus Panel. It is a
call to arms to improve care of the dying. The articles in the
series will provide practical advice and guidance to
Discussing Palliative Care
with PatientsBernard Lo, MD, FACP, Timothy Quill, MD, FACP, and James
Even experienced physicians often struggle when initiating complex,
emotionally laden discussions about palliative care with seriously
ill patients and their families. Two case scenarios illustrate
several communication techniques physicians can use to initiate
Approach To Providing Palliative Care to Patients Who Lack
Decision-Making CapacityJason H.T. Karlawish, MD, Timothy Quill, MD, FACP, and Diane E.
Meier, MD, FACP
Making palliative care decisions when a patient lacks
decision-making capacity presents several challenges. The case and
commentary provided in this paper show how physicians can guide a
process that facilitates good palliative and good care
decision-making for patients who lack capacity.
Management of Pain and
Spinal Cord Compression in Patients with Advanced
CancerJanet L. Abrahm, MD, FACP
Pain and spinal cord compression are two of the most distressing
problems faced by patients with advanced cancer. This paper uses a
case study to illustrate an evidence-based approach to the most
common clinical challenges such patients present.
Dying Patients in the ICU:
Forgoing Treatment, Maintaining CareKathy Faber-Langendoen, MD and Paul Lanken, MD, FACP
This paper considers the care of ICU patients for whom the decision
has been made to limit life-sustaining treatment. It challenges the
misconception that such decisions are decisions to withdraw care,
encouraging physicians to approach the care of patients dying in
the ICU with the same attention to care and compassion that guide
the care of ICU patients expected to survive.
Beyond Good Symptom Management: Opportunities Within
Palliative and End-of-Life Care
(Currently available in
Physician's Guide to End-of-Life Care book)Ira Byock, MD, Arthur Caplan, PhD, and Lois Snyder,
Palliative care is focused on the goals of alleviating suffering
and improving quality of life. Clinical, systemic, financial, and
cultural barriers impose challenges to achieving these goals.
Responding to these barriers requires skillful communication, care,
and symptom management.
Intractable Suffering: The Role of Terminal Sedation and Voluntary
Refusal of Food and FluidsIra Byock, MD and Timothy Quill, MD, FACP
Good palliative care addressing the multiple physical,
psychosocial, and spiritual dimensions of suffering should be the
standard of care for the dying. There remain, however, a few
patients whose suffering is intractable despite excellent care.
This paper discusses terminal sedation and voluntary refusal of
hydration and nutrition as possible last resort responses to severe
end-of-life suffering that has not otherwise been relieved.
Assessing and Managing
Depression in the Terminally Ill PatientSusan Block, MD
Physicians who care for terminally ill patients commonly confront a
range of complex medical and psychosocial questions and challenges.
For many physicians, treating patients who are experiencing
psychosocial distress is particularly difficult. In this paper,
three cases are used to illustrate assessment and management of 1)
normal distress and grieving; 2) clinical depression; and 3) the
wish to hasten death in the presence of psychological distress.
Financing of Care for Fatal
Chronic Disease: Opportunities for Medicare
ReformJoanne Lynn, MD, FACP, Anne Wilkinson, PhD, Lynn Etheridge, and
This paper examines the role of Medicare financing in the care of
persons nearing the end of life and explores how changes might
encourage improved care. Reforms should be guided by better data,
including demonstration and evaluation projects, and by vigorous
and thoughtful discussion.
Reforming Care for
Persons Near the End of Life: The Promise of Quality
ImprovementJoanne Lynn, MD, FACP, Don Berwick, MD, Andrea Kabcenell, RN,
Kevin Nolan, PhD, David Weissman, MD, and Casey Milne
This paper illustrates the method and merits of quality improvement
with regard to care at the end of life. Practical advice is offered
on quality improvement initiatives for immediate
Strategies for Culturally
Effective End-of-Life CareLaVera Crawley, MD, Patricia Marshall, PhD, and Barbara Koenig,
Respecting cultural difference at the end of life requires
physicians to expand the possibilities of what may constitute a
"good death." Differences in beliefs, values, and health-care
practices may provide a challenge to physicians, depending on their
comfort and experience with cultural differences. Increasing
cultural competence can increase physician effectiveness and
Legal Barriers to End-of-Life
Care: Myths, Realities, and Grains of TruthAlan Meisel, JD, Lois Snyder, JD, and Timothy Quill, MD,
Legal myths about end-of-life care can undermine good care and
ethical medical practice. This paper outlines some of these current
myths, followed by a discussion of the reality concerning each
myth, that is, a fair statement of the legal consensus. Given the
variety of state laws and hospital protocols in end-of-life care,
each discussion ends with caveats in the form of "grains of truth"
about each myth.
Life after Death: A
Practical Approach to Grief and BereavementDavid Casarett, MD, Janet Abrahm, MD, FACP, and Jean Kutner,
This consensus paper uses a case-based format to describe essential
aspects of the grieving process, and the corresponding skills and
techniques clinicians need to help those experiencing grief after
the death of a loved one. Recommendations are also provided
regarding interventions and indications for referral.
Diagnosis and Management of
Delirium Near the End of LifeDavid Casarett, MD and Sharon Inouye, MD
Patients near the end of life may face a variety of symptoms that
are distressing and debilitating, perhaps none as detrimental to
quality of life, and as difficult to diagnose and manage, as
delirium. Therefore, appropriate treatment of delirium is a
necessary first step to maximizing patient comfort, optimizing
quality of life, and enhancing the leave-taking process for the
patient and family. This consensus paper presents strategies for
the diagnosis and management of delirium near the end of life, and
concludes with a discussion of strategies for prevention and