Policy Tag: End-of-Life Care

Adopted by the 35th World Medical Assembly, Venice, Italy, October 1983
Revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and by the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

PREAMBLE

When a patient is seriously ill and the restoration of health may not be possible, the physician and the patient are often faced with a complex set of decisions regarding medical treatment.

The end of life must be recognized and respected as an important part of a person’s life.

Advances in medical science have improved the ability of physicians to address many issues associated with end-of-life care. While the priority of research to cure disease should not be compromised, more attention must be paid to developing palliative treatments and improving assessment and response to the physical, psychological, social and spiritual or existential components of terminal illnesses and other conditions at the end of life.

WMA remains firmly opposed to euthanasia and physician-assisted suicide, as set forth in the WMA Declaration on Euthanasia and Physician-Assisted Suicide.

Ethically-appropriate care at the end of life should routinely promote patient autonomy and shared decision-making, and be respectful of the values of the patient, his or her family or intimate associates, and surrogate(s). The WMA recognizes that attitudes and beliefs toward death and dying vary widely from culture to culture and among different religions, and palliative care resources are unevenly distributed. The approach to medical care at the end of life will be influenced significantly by these factors, and thus attempting to develop detailed universal guidelines on terminal care is neither practical nor wise. Therefore, the WMA articulates the following:

 

RECOMMENDATIONS

Pain and Symptom Management

  1. Palliative care at the end of life is part of good medical care. The objective of palliative care is to maintain patient dignity and freedom from distressing symptoms. Care plans should emphasize keeping a patient as comfortable as possible and the patient’s pain controlled while recognizing the importance of attention to the social, psychological and spiritual needs of the patient, and his or her family and intimate associates.
  2. The clinical management of pain in patients at the end of life is of paramount importance in terms of alleviating suffering. The WMA Resolution on Access to Adequate Pain Treatment (2020) makes recommendations for physicians and governments that optimize treatment of pain and other distressing symptoms. Physicians and National Medical Associations should promote the dissemination and sharing of information regarding pain management to ensure that all physicians involved in end-of-life care have access to best practice guidelines and the most current treatments and methods available. National Medical Associations should oppose laws or regulations that unduly inhibit physicians from providing intensive, clinically appropriate symptoms management for patients at the end of life in keeping with recognized best practices.
  3. When a patient at the end of life experiences severe pain or other distressing clinical symptoms that do not respond to intensive, symptom-specific palliation, it can be appropriate to offer sedation to unconsciousness as an intervention of last resort. Sedation to unconsciousness must never be used to intentionally cause a patient’s death and should be restricted to patients in the final stages of life. Thorough efforts should be made to obtain consent of the patient or the patient’s surrogate(s).
  4. Palliative care is often provided by multidisciplinary healthcare teams. When possible, the physician should be the leader of the team, being responsible, amongst other obligations, for diagnosis and medical treatment plans.  A carefully kept medical record is of the utmost importance. The rationale for all symptom management interventions, including medications for symptom relief, should be documented in the medical record, including the degree and length of sedation and specific expectations for continuing, withdrawing, or withholding future life-sustaining treatments.
  5. The health care team should promote collaborative care of the patient and offer bereavement support after the patient’s death. The needs of children and families or intimate associates may require special attention and competence, both when children are patients and when they are dependents of patients.

Education and Research

  1. Education of healthcare professionals should include the teaching of end-of-life medical care. Where it does not exist, the establishment of palliative medicine as a medical specialty should be considered. In countries where palliative medicine is not a recognized specialty, post-graduate training in palliative medicine can nevertheless improve the quality of palliative care provided.
  2. Physician education should help to develop the skills necessary to increase the prevalence and quality of meaningful patient advance care planning for patients with life-threatening illness and the right of patients to use written advance directives that describe their wishes and goals regarding care in the event that they are unable to communicate. Physicians should receive education to encourage their patients to formally document their goals, values and treatment preferences and to appoint a substitute health care decision maker with whom the patient can discuss in advance his or her values regarding health care and treatment.
  3. Governments and research institutions are encouraged to invest additional resources in developing treatments to improve end-of-life care. This includes, but is not limited to, supporting research on general medical care, specific treatments, psychological implications and organization to improve end-of-life care.
  4. When employing treatments, the physician must carefully consider the balance between the intended benefits to the patient and the potential harm. National Medical Associations should support the formulation of palliative treatment guidelines.
  5. The physician must also communicate to the patient a willingness to discuss at any time the natural course of the disease and what to expect during the dying process, while also providing guidance about treatments and alternatives that could ease the patient’s suffering, including palliative care or psychotherapy. If a patient indicates a desire to die or expresses suicidal thoughts, the physician has a duty to engage in open and confidential discussions with the patient to understand the motives and reasoning behind these thoughts.
  6. Physicians should assist the dying patient in maintaining an optimal quality of life by controlling symptoms and addressing psychosocial and spiritual needs, to enable the patient to die with dignity and in comfort. Physicians should inform patients of the availability, benefits and other aspects of palliative care. Discussions about patient preferences should be initiated early, routinely offered to all patients and should be revisited regularly to explore any changes patients may have in their wishes, especially as their clinical condition changes. Information and communication among the patient, his or her family or intimate associates, surrogates and members of the health care team are one of the fundamental pillars of quality care at the end of life.
  7. Physicians should endeavor to identify, understand and address the psychosocial and spiritual needs of their patients, especially as they relate to patients’ physical symptoms. Physicians should try to ensure that psychological, social and spiritual resources are available to patients, their families and intimate associates, to help them deal with the anxiety, fear and grief associated with the end of life.
  8. Physicians should encourage patients to designate a substitute decision-maker/surrogate to make decisions that are not expressed in an advance directive. In particular, physicians should discuss the patient’s wishes regarding the approach to life-sustaining interventions as well as palliative measures that might have the additional effect of accelerating death. Because documented advance directives are sometimes not available in emergency situations, physicians should emphasize to patients the importance of discussing treatment preferences with individuals who are likely to act as substitute health care decision-makers/surrogates. Whenever possible and consented to by the patient, the patient’s substitue decision-makers/surrogates should be included in these conversations.
  9. If a patient has decision-making capacity, his or her autonomous right to refuse any medical treatments or interventions must be respected even if the patient’s life may be shortened. Physicians should make sure that the patient is adequately treated for pain and discomfort before consent for end-of-life care is obtained in order to ensure that unnecessary physical and mental suffering do not interfere with decision making. Laws regarding the decision-making capacity of minor patients vary greatly, but discussions with the family, and child, if possible, are encouraged.
  10. Upon a patient’s death, physicians may apply such means as are necessary to keep organs viable for transplantation, provided that they act in accordance with the ethical guidelines established in the WMA Declaration of Sydney on the Determination of Death and the Recovery of Organs. In addition, any transplantation must be in accordance with the principles in the WMA Statement on Organ and Tissue Donation.

Adopted by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

 

PREAMBLE

In 2017, almost 140,000 solid organ transplants were performed worldwide. Although impressive, this activity provided for only 10% of the global need for transplanted organs. The disparity between supply and demand of organs has led to the emergence of transplant-related crimes, including trafficking in persons for the purpose of the removal of organs and trafficking in human organs.

These crimes violate fundamental human rights and pose serious risks to both individual and public health. The true extent of transplant-related crimes remains unknown, but it is estimated that 5% to 10% of transplants globally take place in the context of the international organ trade, often involving transplant tourism to destinations where laws against the sale and purchase of human organs are nonexistent or poorly enforced. Trafficking in persons for the purpose of the removal of organs and trafficking in human organs can also take place within the boundaries of a given jurisdiction, not involving travel for transplantation. In all cases, the most vulnerable parts of the population often become victims of exploitation and coercion.

Concerned by the increasing demand for organs and by emerging unethical practices in the field, the World Health Organization has called on governments and health professionals to pursue self-sufficiency in transplantation, through strategies targeted at decreasing the burden of diseases treatable with transplantation and increasing the availability of organs, maximising donation from the deceased and ensuring the overall protection of the living donor. Progress towards self-sufficiency in transplantation is consistent with the establishment of official cooperation agreements between countries to share organs or to facilitate patients’ access to transplant programs that have not been developed in their countries of origin. Agreements between countries should be based on the principles of justice, solidarity and reciprocity.

Progress towards self-sufficiency in transplantation is the best long-term strategy to prevent transplant-related crimes.

The distinctive feature of transplant-related crimes is the necessary involvement of health professionals. It is precisely this feature that provides a unique opportunity to prevent and combat these crimes. Health professionals are key in evaluating prospective living donor and recipient pairs. They also care for desperate patients who are vulnerable and at risk of engaging in illicit transplant activities. In addition, since patients who receive a transplant require long-term specialised care, physicians must deal with the many challenges of providing care to patients who have received an organ through illicit means, while unveiling trafficking rings.

International organisations, including the Council of Europe, the European Union and the United Nations, as well as international professional platforms, have developed treaties, resolutions and recommendations for a concerted fight against transplant-related crimes.

The WMA emphasises the responsibility of physicians in preventing and combatting trafficking in persons for the purpose of the removal of organs and trafficking in human organs, as well as the important role of physicians and other health-care professionals in assisting international organisations, medical associations and policy makers in the fight against these criminal activities.

In the fight against transplant-related crimes it is of utmost importance that the principles of transparency of practice, traceability of organs and continuity of care are guaranteed for every transplant procedure performed nationally or abroad.

The WMA reaffirms its Statement on organ and tissue donation and its Declaration of Sydney on the determination of death and the recovery of organs. Condemning all forms of trafficking in persons for the purpose of the removal of organs and trafficking in human organs, the WMA calls for the implementation of the following recommendations.

 

RECOMMENDATIONS

Policy makers and health actors:

  1. Governments should develop, implement and vigorously enforce legislative frameworks that prohibit and criminalise trafficking in persons for the purpose of the removal of organs and trafficking in human organs, these should include provisions to prevent these crimes and protect their victims.
  2. Governments should consider ratifying or acceding to the United Nations Convention against Transnational Organised Crime and the Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, supplementing the United Nations Convention against Transnational Organised Crime, as well as the Council of Europe Convention against Trafficking in Human Organs. They should also consider cooperating with existing international organisations for a more effective fight against transplant-related crimes. The WMA should play a leading role in influencing ethical practices in donation and transplantation.
  3. Health authorities should develop and maintain registries to record information regarding each organ recovery and transplantation procedure, as well as information on the outcomes of living donors and organ recipients, to ensure the traceability of organs, with due regard to professional confidentiality and personal data protection. Registries should be designed to record information on procedures that take place within a country and on transplant and living donation procedures on residents of that country carried out in other destinations.
  4. Countries are encouraged to periodically contribute this information to the Global Observatory on Donation and Transplantation developed in collaboration with the World Health Organization.
  5. Health authorities and medical associations should ensure that all health professionals are trained in the nature, extent and consequences of transplant-related crimes, as well as in their responsibilities and duties in preventing and fighting these criminal activities and in the means to do so.
  6. As self-sufficiency is the best long-term strategy to prevent transplant-related crimes, health authorities and policy makers should develop preventive strategies to decrease the burden of diseases treatable with transplantation and increase the availability of organs.
  7. Increasing organ availability should be based on the development and optimisation of ethically sound deceased donation programs following the determination of death by neurological and by circulatory criteria. Of note is that donation after the determination of death by circulatory criteria is accepted in a limited number of countries. Governments should explore whether donation after the circulatory determination of death is a practice acceptable within their community and, should this be the case, consider introducing it within their jurisdiction.
  8. In addition, governments should develop and optimise living donation programs based on recognised ethical and professional standards and ensure due protection and follow-up of living donors.
  9. Health authorities and/or insurance providers should not reimburse the costs of transplant procedures that have occurred in the context of transplant-related crimes. However, the costs of medications and post-transplant care should be covered, as for any other transplant patient.
  10. Authorities should also ensure that medical and psychosocial care is provided to victims of trafficking in persons for the purpose of organ removal and of trafficking in human organs. Consideration should be given to effective compensation of these persons for the damage suffered.
  11. National Medical Associations should advocate for and cooperate with authorities in developing frameworks for health professionals to report any confirmed or suspected case of trafficking of persons for the purpose of the removal of organs and of trafficking in human organs to the relevant authorities. National Medical Associations should advocate for the ability of health professionals to report suspected trafficking of individual persons, on an anonymous basis if necessary, to protect the safety of the reporter. Where applicable, the reporting of trafficking cases should be a permitted exception to the physician’s obligation to maintain patient confidentiality

Physicians and other health professionals:

  1. Physicians should never perform a transplant using an organ that has been illicitly obtained. If there are reasonable concerns about the origin of an organ, the organ must not be used. If a physician or a surgeon is asked to perform a transplant with an organ that has been obtained through a financial transaction, without the valid consent of the donor or without the authorisation required in a given jurisdiction, they must refrain from performing the transplant and should explain the reasons to the potential recipient.
  2. Physicians who participate in the preoperative evaluation of potential living donors should not only assess the medical suitability of the individual, but also attempt to ensure that the person has not been subject to coercion of any kind or is participating in the procedure for financial gain or any other comparable advantage. The legitimacy of the donor-recipient relationship and the altruistic motivations for donation should be scrutinised. Physicians should be particularly vigilant of “red flags” suggestive of a transplant-related crime. Non-resident living donors may be particularly vulnerable and should be given special consideration. For linguistic, cultural and other reasons, assessing the validity of their consent to donation can be especially challenging, as can ensuring that appropriate follow-up is offered to them. A referring physician should be identified in the country of origin of the living donor – and in that of their intended recipient, where appropriate.
  3. Physicians should never promote or facilitate the engagement of patients in transplant-related crimes. Moreover, they should inform patients of the risks these activities pose for their own health, that of their loved ones and, more generally, for public health. Patients should also understand that these activities entail an exploitation of vulnerable individuals who may themselves suffer from severe medical and psychosocial complications. By counselling patients, professionals may dissuade them from engaging in illicit transplant activities.
  4. Physicians have a duty to care for transplant patients, even if their organ was illicitly Should a physician have ethical or moral objections about caring for a patient who has received an illicit organ, they should make the necessary arrangements to transfer the care of the patient to another physician.
  5. Physicians should contribute to guaranteeing transparency of practices and traceability of organs. When patients who have undergone a donation or a transplantation procedure abroad seek follow-up care in their country of residence, all relevant information should be recorded in national transplant-registries and reported to health authorities, as should happen for all donation and transplantation procedures performed within the national transplant system.
  6. . Physicians have a responsibility to increase the deceased donor pool in order to satisfy the transplantation needs of patients. Physicians also have a duty towards possible organ donors in considering and facilitating organ donation if this is consistent with patients’ values and principles. Donation should be routinely offered as an option at the end of life, always in a respectful manner, taking into account the culture and religion of the potential donor and their surrogates. Conversations about donation opportunities should be led by experienced and trained professionals.
  7. Physicians should promote research in the field of donation and transplantation, in particular research targeted at increasing the availability of organs for transplantation, improving the outcomes of transplanted organs, and identifying alternative organ replacement strategies, as in the case of bioartificial organs.

 

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and rescinded and archived by the 73nd WMA General Assembly, Berlin, Germany, October 2022

INTRODUCTION

All people have the right to high-quality, scientifically-based, and humane healthcare. Therefore, receiving appropriate end-of-life medical care must not be considered a privilege but a true right, independent of age or any other associated factors. The WMA reaffirms the principles articulated in the WMA Declaration on Terminal illness and the WMA Declaration on Euthanasia. These Declarations support and complement the Declaration on End of Life Medical Care.

Palliative care at the end of life is part of good medical care. The need for access to improved quality palliative care is great, especially in resource-poor countries. The objective of palliative care is to achieve the best possible quality of life through appropriate palliation of pain and other distressing physical symptoms, and attention to the social, psychological and spiritual needs of the patient.

Palliative care may be provided at home as well as in various levels of health care institutions.

The physician must adopt an attitude to suffering that is compassionate and humane, and act with empathy, respect and tact. Abandonment of the patient when he or she needs such care is unacceptable medical practice.

RECOMMENDATIONS

1.            Pain and symptom management

1.1  It is essential to identify patients approaching the end of life as early as possible so that the physician can perform a detailed assessment of their needs.  A care plan for the patient must always be developed; whenever possible, this care plan will be developed in direct consultation with the patient.

For some this process may begin months or a year before death is anticipated. It includes recognising and addressing the likelihood of pain and other distressing symptoms and providing for patients’ social, psychological and spiritual needs in the time remaining to them. The primary aim is to maintain patients’ dignity and their freedom from distressing symptoms. Care plans pay attention to keeping them as comfortable and in control as possible and recognise the importance of supporting the family and treating the body with respect after death.

1.2  Important advances in the relief of pain and other distressing symptoms have been made. The appropriate use of morphine, new analgesics, and other measures can suppress or relieve pain and other distressing symptoms in the majority of cases. The appropriate health authorities must make necessary medications accessible and available to physicians and their patients. Physician groups should develop guidelines on their appropriate use, including dose escalation and the possibility of unintended secondary effects.

1.3  In a very limited number of cases, generally in the very advanced stages of a physical illness, some symptoms may arise that are refractory to standard therapy. In such cases, palliative sedation to unconsciousness may be offered when life expectancy is a few days, as an extraordinary measure in response to suffering which the patient and clinician agree is intolerable. Palliative sedation must never be used to intentionally cause a patient’s death or without the agreement of a patient who remains mentally competent. The degree and timing of palliative sedation must be proportionate to the situation. The dosage must be carefully calculated to relieve symptoms but should still be the lowest possible to achieve a benefit.

2.            Communication and consent; ethics and values

2.1  Information and communication among the patient, their family and members of the health care team is one of the fundamental pillars of quality care at the end of life. The patient should be encouraged to express his or her preferences regarding care, and his or her emotions and existential angst must be taken into consideration.

2.2  Ethically-appropriate care at the end of life should routinely promote patient autonomy and shared decision-making, and be respectful of the values of the patient and his or her family.

2.3  Physicians should directly discuss a patient’s preferences with the patient and/or the patient’s substitute health care decision maker, as appropriate. These discussions should be initiated early and routinely offered to all patients and should be revisited regularly to explore any changes patients may have in their wishes, especially as their clinical conditions change. Physicians should encourage their patients to formally document their goals, values and treatment preferences and to appoint a substitute health care decision maker with whom the patient can discuss in advance his or her values regarding health care and treatment. Patients who are in denial about the implications of their condition may not want to engage in such discussion at some stages of their illness, but should know that they can change their minds. Because documented advance directives are often not available in emergency situations, physicians should emphasize to patients the importance of discussing treatment preferences with individuals who are likely to act as substitute health care decision makers.

2.4  If a patient is capable of giving consent, care should be based on the patient’s wishes as long as preferences can be justified medically, ethically and legally. Consent needs to be based on sufficient information and dialogue, and it is the physician’s obligation to make sure that the patient is adequately treated for pain and discomfort before consent is obtained in order to assure that unnecessary physical and mental suffering do not interfere with the decision-making process.

2.5  The patient’s next-of-kin or family should be informed and involved in the decision-making process, provided the patient is not opposed to this. If the patient is unable to express consent and an advance directive is not available, the views of the health care substitute decision maker, appointed by the patient on care and treatment, must be considered.

3.            Medical records and medico-legal aspects

3.1  Physicians caring for a patient in the final stages of life must carefully document treatment decisions and the reasons for choosing particular procedures, including the patient’s and family’s wishes and consent, in the progress notes of the medical records. An adequate medical record is of the utmost importance for continuity and quality of medical care in general and palliative care in particular.

3.2  The physician must also take into account that these notes may serve a medico-legal purpose, e.g., in determining the patient’s decision-making capacity.

4.            Family members

It is necessary to acknowledge the importance of the family and the emotional environment of the patient. The needs of the family and other close caregivers throughout the course of the illness must be recognized and attended to. The heath care team should promote collaboration in the care of the patient and provide bereavement support, when required, after the patient’s death. Children’s and families’ needs may require special attention and competence, both when children are patients and dependents.

5.            Teamwork

Palliative care is usually provided by multiprofessional and interdisciplinary teams of healthcare and non-healthcare professions. The physician must be the leader of the team, being responsible, amongst other obligations, for diagnosis and medical treatment.  Continuity of care is very important. The team should do all it can to facilitate a patient’s wish to die at home, if applicable and possible.

6.            Physician training

The increasing number of people who require palliative care and the increased availability of effective treatment options mean that end-of-life care issues should be an important part of undergraduate and postgraduate medical training.

7.            Research and education

More research is needed to improve palliative care.  This includes, but is not limited to, general medical care, specific treatments, psychological implications and organization.  The WMA will support efforts to better educate physicians in the skills necessary to increase the prevalence and quality of meaningful advance care planning.

CONCLUSION

The care that a people give to dying patients, within available resources, is an indication of their degree of civilisation. As physicians representing the best humanitarian tradition, we should always commit ourselves to delivering the best possible end-of-life care.

The WMA recommends that all National Medical Associations develop a national policy on palliative care and palliative sedation based on the recommendations in this declaration.

Adopted by the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
And amended by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

 

PREAMBLE

Around the world, tens of millions of people with cancer and other diseases and conditions experience moderate to severe pain without access to adequate treatment. These people face severe suffering, often for months on end, and many eventually die in pain. Those who may not be able to adequately express their pain – such as children, people with intellectual disabilities and those with altered consciousness– and individuals and populations that have historically been undertreated for pain and pain management due to bias, are especially at risk of receiving inadequate pain treatment.

Inadequate pain treatment contributes to individual suffering physically and emotionally, but also causes huge care burdens and negative economic impact on a national level.

However, most of the suffering is unnecessary and is almost always preventable and treatable.

In most cases, pain can be stopped or relieved with inexpensive and relatively simple treatment interventions, which can dramatically improve the quality of life for patients. Sometimes, especially in severe chronic pain, psycho-emotional factors are even more significant than physiologic factors.

Pain treatment in these cases may require a multi-faceted approach to care by multidisciplinary teams.

Over the years, the use of opioids has seen significant growth in some countries. In many other areas around the world, however, access to essential pain treatment remains limited for patients in pain. Even in countries with a high volume of use, it can be difficult for specific populations to receive adequate treatment for their pain. Incomplete pain assessment or improper use of pain medication can bring about adverse drug reactions. All of these are very important and urgent issues need to be addressed.

Governments should adopt effective measures, wherever possible, for adequate pain treatment. For this goal, governments shall ensure that healthcare professionals across fields are entitled to educational training on pain evaluation and management; that the right of all patients in pain to pain treatment is not compromised due to unnecessary regulations; and that policies on the management of controlled drugs help with effective monitoring of and prevention against risks associated with controlled drugs.

 

RECOMMENDATIONS

  1. Access to adequate pain treatment is a human right. Physicians, medical professionals and health care workers must offer pain assessment and pain treatment to patients with pain. Governments must provide sufficient resources and proper pain treatment regulations.
  2. Pain is a complex perception consisting of physical, psychological, social, cultural and spiritual sufferings. Physicians, medical professionals and health care workers must offer holistic pain assessment and appropriate pain treatment, such as pharmacological and/or non-pharmacological interventions to patients with pain. All healthcare professionals should seek to fulfill the goal of effectively evaluating the pain of all patients, including pain suffered by children, cognitively impaired patients and those unable to properly express themselves.  Healthcare professionals should also seek to effectively evaluate and treat pain in patients and populations who have historically been undertreated for pain due to implicit and explicit biases.
  3. Pain treatment and control education shall be provided to healthcare professionals including physicians, other medical professionals, and other health care workers.

Education should include pain assessment, evidence-based pain control, and the efficacy and risks of painkillers. Education should include pain medicine, including the action of opioids, preventing adverse reactions, and the adjustment and conversion of the dosage of opioids. Patient-centered care should be taught to fulfill the goal of adequately stopping pain and reducing the incidence of adverse reactions. The curriculum shall be highly competence-based in design enhancing the knowledge, the attitude, and the skills of healthcare professionals while treating pain.

Education should support the development of pain and palliative specialists, in order for them to effectively support first-line physicians and other medical professionals.

Pain treatment education for medical professionals shall include the non-medicinal treatment options. Education should equip medical professionals with proper interpersonal communication skills, cultural sensitivity, and the ability to evaluate the overall pain suffered by patients at the physiological, psychological, and spiritual levels and to empower them in inter-professional practice so that professionals can work together to alleviate the pain felt by patients with and without medication.

  1. Governments, regulators and healthcare administrators must acknowledge the consequences of pain in terms of health, productivity, and economic burden. Governments should provide ample resources and have suitable regulations governing controlled drugs.

For policies on the control of drugs, governments shall periodically review and adequately revise them to ensure the availability and accessibility of controlled drugs such as opioids. In addition, abuse and illicit use must be prevented.

  • Patients in pain shall be given access to effective pain medication, including opioids. Depriving them of such right is a violation of their right to health and is medically unethical.
  • Governments must ensure that controlled drugs, including opioids, are made available and accessible to help relieve the suffering. Relief of suffering and prevention against abuse shall be balanced in the management of controlled drugs.

Government shall provide abundant resources and create a national pain management research institute to explore issues in pain treatment and to come up with solutions, in particular:

  • Explore issues that become barriers to pain treatment, such as financial condition, socioeconomic status, patient race and ethnicity, urban and rural differences, logistics, insufficient training, and culture (the misunderstanding that people have about opioids, for example)
  • Promote the use of validated pain assessment tools.
  • Conduct studies of emerging therapies or non-medicinal therapies.
  • Establish a system and a standard procedure to record and collect pain-related data for correct statistics and monitoring. Pain-related data includes the incidence and prevalence of pain, cause of pain, burden of pain, pain treatment status, reason for pain not properly treated, and number of people with drug abuse, etc.
  1. Governments shall prepare a national pain treatment plan to be followed in pain prevention, pain treatment, pain education, and policies on the management of controlled drugs.
  • The national pain treatment plan shall be evidence-based.
  • Governments must take into consideration opinions of policymakers, medical professionals, and the general public in order to prepare a national pain treatment plan that is extensive, practical, and forward-looking, contributing to enhanced nationwide pain treatment efficacy.

Adopted by the 39th World Medical Assembly, Madrid, Spain, October 1987,
and reaffirmed by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005 and by the 200th WMA Council Session, Oslo, Norway, April 2015,
and rescinded and archived by the 70th WMA General Assembly, Tbilisi, October 2019
* This document has been replaced by the completely rewritten  “WMA Declaration on Euthanasia and Physician-Assisted Suicide” (2019)

 

Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.

Adopted by the 54th WMA General Assembly, Helsinki, Finland, September 2003
reaffirmed by the 194th WMA Council Session, Bali, Indonesia, April 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE 

An advance directive is a written and signed document or a witnessed verbal statement whereby persons record their wishes regarding the medical care they wish to receive, or not receive, if they become unconscious or otherwise unable to express their will.

This type of document may have different names in different countries (e.g., “living will” or “biological wills”). The acceptability and legal status of such directives may differ from one country to another, depending on social, cultural, religious and other factors.

The majority of persons who draw up such directives are particularly concerned about excessive, ineffective or prolonged therapeutic interventions in the terminal phases of life, in situations where there is clear and irreversible physical or mental degeneration.

The WMA Declaration of Lisbon on the Rights of the Patient states that if the patient is unconscious and “if a legally entitled representative is not available, but a medical intervention is urgently needed, consent of the patient may be presumed unless it is obvious and beyond any doubt on the basis of the patient’s previous firm expression or conviction that he/she would refuse consent to the intervention in that situation.”

 

RECOMMENDATIONS

  1. A patient’s duly executed advance directive should be honoured unless there are reasonable grounds to suppose that it is not valid because it no longer represents the wishes of the patient or that the patient’s understanding was incomplete at the time the directive was prepared. If the advance directive is contrary to the physician’s convictions, provisions should be made to transfer the care of the patient to another consenting physician.
  2. If the physician is uncertain about the validity of an advance directive to terminate life-prolonging treatment, he/she should consult family members or legal guardians of the patient concerned and should seek advice from at least one other physician or the relevant ethics committee. The family members or legal guardians should be designated in the advance directive, be trustworthy and willing to testify as to the intention(s) expressed in the advance directive by the signatory. The physician should consider any relevant legislation concerning substitute decision making for incompetent patients.
  3. Patients and their family members should be educated on the possibility of having living wills and advised to review their advance directives periodically.
  4. In the absence of an advance directive or a legally designated substitute decision maker, physicians should render such treatment as they believe to be in the patient’s best interests.
  5. Constituent Members of countries that do not have adequately developed legal frameworks and hospital protocols for advance directives, are encouraged to work with relevant authorities to develop such frameworks, integrate these changes both in the medical curricula and public education, as well as promote awareness among practicing physicians through continuing professional development programs.