Compassion and communication for both patients and families are among the most important factors involved in providing end-of-life care.
Published in AMA Journal of Ethics, the authors outlined practice guidelines for end-of-life patient care per the American Medical Association Code of Medical Ethics.
The AMA Code describes advance care planning and respect for patient autonomy as the cornerstones of proper end-of-life care. Physicians should obtain an “advance directive” from patients so that in the event of loss of the patient’s decision-making capacity, physicians and/or surrogate decision makers can carry out the patient’s wishes appropriately. Ascertaining the patient’s preferences through transparent communication is key to navigating later clinical decision making, the guideline authors wrote, and advance care discussions should be initiated early in the physician-patient relationship, regardless of age or health status.
The AMA Code also addresses scenarios in which patients or their families refuse life-sustaining care or wish to create a do-not-attempt-resuscitation (DNAR) order. Similar to advance care directives, DNAR orders should be included in a patient’s medical record and discussed clearly with patients prior to their generation. The Code states that DNAR orders do not apply to non-life-sustaining medical interventions, such as palliative care. As practitioners, the Code states, medical professionals must emphasize the comfort of their patients and continue to provide symptom management when appropriate, even when a DNAR order has been generated.
The guideline authors also described the Code recommendations on “sedation to unconsciousness in end-of-life care,” emphasizing that such procedures are reserved for patients in the final stages of terminal illness. In addition, the Code states, sedation is reserved only for pain that cannot be addressed with other forms of palliation, and is not to be used to alleviate psychological distress. The Code recommends against physician-assisted suicide and euthanasia, describing these practices as “incompatible with the physician’s role as healer.” Although some patients and physicians may mutually agree on such procedures, the Code explicitly qualifies them as “[posing]…societal risks.”
The guidelines of the AMA Code of Medical Ethics are recognized as crucial to physician navigation of end-of-life clinical situations. Physician sensitivity to patient and family concerns, transparent communication, and careful documentation and planning are central to appropriate accommodation of patients during end-of-life care.
Reddy R, Hahn Chaet D. AMA Code of Medical Ethics’ Opinions Related to End-of-Life Care. AMA J Ethics. 2018;20(8):E738-E742.