and the means of preventing and relieving physical, psychological, and spiritual distress.

In the policy arena, by establishing limited Medicare coverage for hospice care, the government acknowledged the special needs of dying patients and those close to them. Legislators and judges have also attempted to give patients and their families more control over the way death occurs through policies that require informed consent to treatment, encourage planning in anticipation of death, and recognize patients' (and surrogates') right to stop medical interventions.

The time is right for further action at all levels to improve care for those approaching death and to assure the fearful that they will be neither abandoned nor maltreated. The intense debate over assisted suicide appears to be increasing public recognition of deficits in end-of-life care and consolidating agreement among proponents and opponents alike that people should not view suicide as their best option because they lack effective and compassionate care as they die.1 As discussed further below, a small but growing number of initiatives are beginning to tackle a wide array of health care and other deficiencies that contribute to poor care at the end of life. In addition, a number of widely publicized books and stories have portrayed dying and death in ways that are realistic and positive but also sensitive to popular fears and concerns. On a more personal level, news reports on public figures such as Richard Nixon, Jacqueline Kennedy Onassis, and Joseph Cardinal Bernardin have portrayed older people with incurable illnesses preparing for and meeting death with grace and courage.

The goals of this Institute of Medicine (IOM) report are to extend understanding of what constitutes good care at the end of life and to promote a wider societal commitment to create and sustain systems of care that people can count on for spiritual, emotional, and other comfort as they die. More specifically, it is intended to stimulate health professionals and managers, researchers, policymakers, funders of health care, and the public at large to develop more constructive perspectives on dying and death and to change practices, policies, and attitudes that contribute to distress and suffering at the end of life.

This report focuses on health care-related aspects of dying including clinical and supportive services, financing of such services, and professional education. These are, of course, only a part—often a minor part—of the dying process as experienced by patients and those close to them. The support of family and friends, religious congregations, workplaces, and

1  

While this report was being prepared, two cases involving assisted suicide were argued before the U.S. Supreme Court. The Court ruled on June 30, 1997 (after this report was publicly released) that there is no general constitutional right to physician assistance in suicide. See Chapter 7 for further discussion.



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