Intro 1963-88 1989-96 1997-2003 2004 - Bibliography To search within the timeline, or to print all 28+ pages, click here
2-page overview of
the history, in PDF format.
short version
Euthanasia Timeline

RWJF launches $28 million study of dying in America ("SUPPORT"); the first step in what would become a 15-year campaign to change America's "Culture of Denial."

RWJF funded "Program on the Care of Critically Ill Hospitalized Adults" at George Washington University. That program conducted the "Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments," known to this day as the SUPPORT study. Joanne Lynn and William Knaus designed the study.

National Coordinating Center: George Washington University
Research sites for study of dying patients:

  1. Beth Israel Hospital in Boston;
  2. Cleveland MetroHealth Medical Center;
  3. Duke University Medical Center (Durham, NC);
  4. Marshfield Medical Research Foundation (Marshfield, WI);
  5. UCLA School of Medicine.
Researchers included Joan Teno, MD; Stuart Youngner, MD; Donald J. Murphy, MD.

[Next:  Hastings Center introduces SUPPORT.]
1989 Mar

Wanzer, S. H., D. D. Federman, S. J. Adelstein, C. K. Cassel, E. H. Cassem, R. E. Cranford, E. W. Hook, B. Lo, C. G. Moertel, P. Safar, and et al. "The Physician's Responsibility toward Hopelessly Ill Patients. A Second Look." N Engl J Med 320, no. 13 (1989): 844-849.

This was a "second look" at the issue of assisted suicide, as addressed in the 1984 article also titled "The Physician's Responsibility toward Hopelessly Ill Patients." This 1989 article is generally recognized as a reference in support of physician-assisted suicide.


World Health Organization defines "palliative care" as "the active total care of patients whose disease is not responsive to curative treatment . . . [when] control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount."  [WHO (World Health Organization). Cancer Pain Relief and Palliative Care. WHO Technical Report Series 804. Geneva: WHO, 1990.]

1990 Oct

Patient Self-Determination Act -- Sponsored by Sen. John Danforth, R-MO. Danforth's advisor was Myra Christopher, now at the Center for Practical Bioethics (formerly known as the Midwest Bioethics Center). Myra Christopher and Midwest Bioethics later become key players in Last Acts. [ 1999, Community-State Partnerships, below.]

1990 Dec

Cruzan case decided; Nancy Cruzan dies. This has been called the first Supreme Court right-to-die case, and established the precedent for the Oregon assisted dying law. 

Radford professor Matthew J. Franck explains that the Cruzan decision set the stage for Terri Schiavo's death. From an opinion piece in National Review, March 30, 2005:.

At first glance the Cruzan decision may have seemed to be a pro-life ruling. After all, the immediate effect was to keep Nancy Cruzan alive, and to endorse, in the law, a state's presumption in favor of life. The hysterical ire of four dissenting justices who wished to make death an easier choice seemed to bolster the good-news interpretation of Cruzan at the time. And the Court's opinion by Chief Justice William Rehnquist did hold that "a State may properly decline to make judgments about the 'quality' of life that a particular individual may enjoy, and simply assert an unqualified interest in the preservation of human life."

The sentence I just quoted did not end there, however, but continued as follows: "to be weighed against the constitutionally protected interests of the individual." And therein lies the twofold failure of Rehnquist's reasoning in this case.

First, the chief justice identified the "preservation of human life" not as a principle but as a mere "interest," however "unqualified" with respect to "'quality' of life." And unlike principles, which a court vindicates and defends against violation, interests, as Rehnquist noted, are to be "weighed" against other interests. This is the ordinary work of legislators, but here Rehnquist embraced the trend of recent decades that it is also the work of judges when deciding constitutional cases.

What is the "constitutionally protected interest" that is to be weighed in the balance against the state's interest in life? Here is Rehnquist's second error, and the one that sets us on the road to the deathwatch in Pinellas Park, Florida. Holding, on the thinnest basis in precedent, that under the Fourteenth Amendment "a competent person has a constitutionally protected liberty interest in refusing unwanted medical treatment," the chief announced with astonishing casualness that "for purposes of this case, we assume that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition."

William Colby represented the Cruzan family, demanding Nancy Cruzan's removal from life support.  William Colby would become a fellow at Midwest Bioethics Center, and would tour hospices as a speaker for Rallying Points.  (1999, Community-State Partnerships, below)

1991   owlSociety for the Right to Die and Concern for Dying merge to form
Choice in Dying
1991 Mar New England Journal of Medicine publishes an article by Timothy Quill (University of Rochester) in which he describes in detail how he helped his patient — "Diane"— kill herself.
"Death and dignity. A case of individualized decision making." New England Journal of Medicine, March 7, 1991; 324(10): pp. 691-4.

Christine Cassel, MD; Diane Meier, MD; Timothy Quill, MD, produce some of the first published guidelines for assisted suicide: "Care of the hopelessly ill: Proposed clinical criteria for physician-assisted suicide." New England Journal of Medicine, November 5, 1992; 327(19): pp. 1380-4.

Six years later Cassel, Quill, and Meier team up with Sean Morrison to author a "Survey of Physician-Assisted Suicide and Euthanasia," published in NEJM. Meier's letter claiming a "change of heart" on PAS is published in the New York Times immediately after. The next year (1999), the Robert Wood Johnson Foundation grants Meier and Cassel nearly $5 million to found the Center to Advance Palliative Care (CAPC).

1992   Ira Byock brings Chalice of Repose Project to Missoula, Montana.  Chalice of Repose is "a school of music-thanatology. . . . Its faculty and students keep vigil at the bedsides of the dying with singing and playing the harp. "
1993 Apr PAS proponentCompassion in Dying is founded in Washington.  Barbara Coombs Lee writes: "At the peak of the AIDS epidemic, eleven activists establish Compassion in Dying in Seattle, Washington and publicly declare their intention to counsel mentally competent, terminally ill patients on aid in dying."  ["Aid in dying" becomes a euphemism for physician-assisted suicide.]
1993 Jul RWJF announces an initial investment of $23 million in an interfaith caregiver programFaith in Action (FIA).  FIA replicates RWJF's 1983 "Interfaith Volunteer Caregivers Program."   The program provided seed money ($25,000) to interfaith "coalitions" to aid caregivers.    Faith in Action was not officially one of RWJF's EOL projects; but the coalitions serve people with chronic illnesses, AIDS, and dementia, so the program dovetails with the EOL program.  Many of the Faith in Action grants went to coordinators at hospices.  Also note the tie-in with EPEC2:  Della Reese would present a Faith in Action keynote address at IIPCA's "Last Miles of the Way Home" (see "Last Miles," February, 2004).

There were two waves of funding for FIA:  Faith in Action II (or "Generation 2") authorized $40 million from 1993-1999.  FIA III (1999-2002) authorized $50 million.

Next: see Faith in Action (in February 2001: national program office moves to Wake Forest University in North Carolina).

1993 Dec First step towards IOM's futility guidelines: 
Institute of Medicine (IOM) "Workshop on Dying, Decisionmaking, and Appropriate Care" in DC.

IOM had been asked to "develop guidelines for identifying and limiting futile treatments" (see "Preface" at This workshop determined whether development of guidelines would be feasible. Funded by Commonwealth Fund, in anticipation of SUPPORT results.
Presenters included: Christine Cassel, Kathleen Foley, Robert Burt, Barbara Koenig, and Neil MacDonald.  Joanne Lynn and Joan Teno gave a presentation on SUPPORT (two years before publication of SUPPORT results).

1994   Supportive Care of the Dying, a consortium of Catholic health care providers, is founded in Oregon in response to legalization of PAS.
1994   PAS proponentsDeath With Dignity Education Center is founded in California.

Choice in Dying directs a 5-year project: Integrating Education about Care of the Dying into Existing Medical School Programs. Supported by a grant of over $349,000 from the Greenwall Foundation, Karen Kaplan reported (Transforming Death in America, 2001) that the project "provided a laboratory for 12 medical schools in which they could experiment with various approaches to improving existing curricula about end-of-life care." Participants included

  • Yale Univ. School of Medicine (Nancy Angoff, MD)
  • Washington University School of Medicine, St. Louis, MO (Ellen Binder, MD)
  • Univ. of California Medical School (Molly Cooke, MD)
  • Hahnemann University, Philadelphia (Janet Fleetwood, PhD)
  • Dartmouth Medical School (Sarah Goodlin, MD)
  • University of Miami, Forum for Bioethics & Philosophy (Kenneth Goodman, PhD)
  • University of Washington, Seattle, WA (Thomas McCormick, D.Min)
  • Loyola University School of Medicine (Myles Sheehan, MD)
  • East Tennessee State University (Tom Townsend, MD)
  • State University of New York, Stony Brook (Peter Williams, PhD, JD)
  • Univ. of Texas Medical Branch at Galveston (William Winslade, PhD, JD,; also with Choice in Dying)
  • Choice in Dying:
    - William A. Nelson, Ph.D. (also for Veterans Health Administration National Center for Ethics)
    - Karen Orloff Kaplan
    - Mary L. Meyer
1994 Oct Arthur Caplan convenes a "Bioethics Mega-meeting" in Pittsburgh, PA, 10/6-10/9/1994. This is the first concurrent meeting of the American Association of Bioethics, American Society of Law, Medicine and Ethics, Society for Bioethics Consultation and the Society for Health and Human Values. Theodore Marmor delivered a keynote address on healthcare reform; lamented that the news media did not properly explain the plan and process to the public.
1994 Nov Overt proponents of PASOregon Death With Dignity Act (Measure 16) is approved by voters.  Oregon Right to Life provides a good summary of the subsequent events.
1994 Nov Reagan announces he has Alzheimer's; goes into seclusion. (He lives almost a decade.)
1994 Nov

George Soros delivers a speech at Columbia Presbyterian Medical Center (NY), explaining how and why he created Project on Death in America. He says that his mother had been a member of the Hemlock Society, and he approves of the Oregon law just passed; but he does not speak for PDIA, which is taking a neutral position.

The next month, the foundation issues a formal press release announcing  Project on Death in America. To start, Soros invests $15 million over 3 years.

1995   Robert Wendland's wife refuses to allow his feeding tube to be reinserted.  For information on the ensuing case, see
1995   Overt proponents of PASOregon Death with Dignity Legal Defense and Education Center is founded for the purpose of defending Oregon's Ballot Measure 16 to legalize PAS.
1995   American Alliance of Cancer Pain Initiatives is launched (from Wisconsin Cancer Pain Initiative).

National Hospice Work Group (NHWG) is founded.   True Ryndes, RN, who was a board member of Partnership for Caring, was President and CEO of the NHWG.
The Spring, 2001, Partnership for Caring newsletter describes NHWG:

"The National Hospice Work Group was founded six years ago to increase access to hospice and palliative care. It is a coalition of 20 progressive hospice programs around the country whose members include activists who pioneered the hospice movement in the ‘70s and '80s and those who provide fresh professional insights from other industries. . . .

Productive and Proactive
The National Hospice Work Group functions as both a 'think tank' and a 'work tank.'  Its members meet four times a year to share 'best practices.' Best practices are demonstrated ways to provide cost-effective care while maintaining excellent patient outcomes. The Group also develops federal policy recommendations and constructs tools that the hospice community can use to demonstrate the benefits of hospice care."
1995 Mar Evangelium vitae (March 25)
1995 Apr

April: Ira Byock, in American Journal of Hospice and Palliative Care:

"In my own practice, while I steadfastly refuse to write a prescription with lethal intent or otherwise help the patient commit suicide, I can share with the patient information that he or she already has the ability to exert control over the timing death. Virtually any patient with far-advanced illness can be assured of dying -- comfortably, without any additional physical distress -- within one or two weeks simply by refusing to eat or drink."


Soros's first round of Open Society Institute and Project on Death in America Faculty Scholars include:

Diane Meier,
Judith C. Ahronheim,
Jane Morris,
Sean Morrison OSI Scholars at Mt. Sinai Medical Center in NY;
Andrew Billings ( OSI Scholar, MGH/Harvard);
Wm. Breitbart (OSI Scholar, Memorial Sloan-Kettering /Cornell);

Nicholas Christakis (U.Chicago);
Stuart Farber (U. Wash.);
Carlos Gomez (U.Va.);
Sarah Goodlin (White River Junction, VT and Dartmouth);
Steven Miles (U.Minn; Wanglie case);

Thomas Smith (Va. Commonwealth);
James Tulsky (Duke);
Charles von Gunten (Northwestern);
David Weissman (Med. Coll. of Wisconsin).
1995 Aug Oregon: District court judge declares Death With Dignity Act (Measure 16) unconstitutional.  The decision would be appealed to the Ninth District Court of Appeals (see February, 1997).
1995 Nov

Hastings Center Report (special supplement, paid for by RWJF; Nov.–Dec. 1995.) Dying Well in the Hospital: the lessons of SUPPORT.

Daniel Callahan worries that [bellicose] America is waging a "war against death." We must accept death. Outlines strategy for campaign against death-denying society:

  1. Communication;
  2. Institutional change;
  3. Public engagement.

Callahan's three-pronged strategy will form the basis for the first RWJF Last Acts conference in 1996.

[Next:  SUPPORT is published; and Last Acts is launched.]

1995 Nov

Soros' foundation hosts conference at Project on Death in America headquarters: Cummings, RWJF, Commonwealth, AARP and others ("Grantmakers Concerned with Care at the End of Life"). Participants included:

Susan Block, M.D., Soros/PDIA Faculty Scholars program;
Thomas Bryant, M.D., J.D., Non-Profit Management Associates, Inc.;
Christine Cassel, M.D., Milbank Memorial Fund, and Mt. Sinai Medical School Dept of Geriatrics;
Susan Clark, Columbia Foundation;
Karen Davis, Commonwealth Fund;
John Feather, AARP Andrus Foundation;
Kathleen Foley, M.D., Soros/PDIA;
Rosemary Gibson, Robert Wood Johnson Foundation;
David Gould, Ph.D., United Hospital Fund;
Charles Halpern, Nathan Cummings Foundation;
Herbert Hendin, American Suicide Foundation;
Andrea Kydd, Nathan Cummings Foundation;
Thomas Layton, Gerbode Foundation;
Elizabeth Lorant, Soros/Open Society Institute;
Joanne Lynn, M.D., MA, MS., Soros/PDIA board member;
Len McNally, NY Community Trust;
Donald Murphy, M.D., Colorado Collective for Medical Decisions;
Aryeh Neier, Soros/Open Society Institute;
Patricia Prem, M.S.W., Soros/PDIA;
David Rothman, Soros/PDIA;
Fenella Rouse, J.D., Kornfeld Foundation and Mayday Fund;
William Stubing, Greenwall Foundation;
Charles Terry, Rockefeller family; and
Mary Ann Zehr, Council on Foundations

1995 Dec

SUPPORT published in Journal of the American Medical Association (JAMA)
"A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments (SUPPORT)." JAMA. 1995; 274:1591-1598.


Professional educationEPEC Project (Education for Physicians on End-of-Life Care)
Linda Emanuel [who was raised and educated in England; degrees from Oxford and Cambridge], develops the EPEC curriculum with Charles F. von Gunten, MD, PhD; Frank D. Ferris, MD [Canadian]; and Russell Portenoy, MD.

RWJF invested $5 million. Soros/PDIA supported the additional leadership through faculty scholarships: von Gunten was PDIA faculty scholar in 1995; Ferris and Portenoy would be named faculty scholars in 1998.

1996 Mar Institutional ChangeMissoula Demonstration Project (which later became Life's End Institute) is founded in Missoula, Montana, by Ira Byock and Barbara Spring.  Initial funding came from Nathan Cummings Foundation and Project on Death in America.  In addition, Mayday provided $150,000 (1996-1999) for Missoula's "Pain as the Fifth Vital Sign" project, conducted by Linda Torma, MSN.  In 1999, executive director Barbara Spring would be replaced by bioethicist Mark Hanson of the Hastings Center.  Hanson would also become interim director of the Practical Ethics Center at Univ. of Montana (headquarters for Promoting Excellence -- see below ).
1996 Mar

Last Acts calls its First National Leadership Conference in Arlington, Virginia, on March 12. The one-day conference was designed around Daniel Callahan's three-point strategy to change America's culture of denial:

  1. Communication (Later, following IOM's recommendations, this changed to "professional education" for grantmaking purposes. The SUPPORT study had been a failure in terms of physician/patient communications);
  2. Institutional change;
  3. Public engagement.

We have provided a list of participants in the first Last Acts conference on a separate page.

The conference featured the following speakers and facilitators:  Thomas Delbanco, M.D. (Beth Israel Hospital; Picker Institute); Kathleen Foley, M.D. (Memorial Sloan-Kettering; Soros/PDIA ); William Knaus, M.D. (Univ. of Virginia School of Medicine); Jonathan Lord (American Hospital Association); Joanne Lynn, M.D.  (Center to Improve Care of the Dying); Laurence O'Connell, Ph.D.  (Park Ridge Center for the Study of Health, Faith); Steven Schroeder, M.D  (RWJF President); Paul Armstrong, J.D., L.L.M. Timins & Associates (Armstrong was lawyer for the family of Karen Ann Quinlan); Elizabeth Clark, Ph.D., ACSW  (Albany Medical Center / National Coalition for  Cancer Survivorship); Michelle Ervin, M.D.  (Howard University Hospital; Soros/PDIA Faculty  Scholar 1998); Joan Harrold, M.D., MPH (Center to Improve Care of the Dying); Barbara Koenig, Ph.D. (Stanford Center for Biomedical Ethics; Soros/PDIA ); Mildred Solomon, Ed.D. (Education Development Center, Newton, MA).

This meeting generated a list of objectives and tactics -- or "Challenges" and "Opportunities":

  1. Create opportunities for talking about death
  2. Change the language about dying ("Establish working relationships with educators in secondary school systems, particularly those who teach family life or health, aimed at making the vocabulary of death and dying more natural." Example: Soros-funded "Grief at School Program")
  3. Promote Advance Care planning
  4. Improve communications skills of health care professionals
  5. Strengthen health care professional education related to death and dying.
  6. Palliative Care -- make it an integral part of patient care. (normalize it; move it upstream)
  7. Quantify. Develop measurement measures. (Outcome-based death)
1996 Apr IOM's Committee on Care at the End of Life - Public Hearing #1  on April 29 at National Academy of Sciences, Washington, DC.  (IOM's second step toward futility guidelines, published in  "Approaching Death").  Led by Christine Cassel; panelists included Joseph Fins (American Geriatrics Society); Kim Calder (American Alliance of Cancer Pain Initiatives); Linda Blank (ABIM); Thomas Reardon (AMA); Ira Byock (Academy of Hospice Physicians); Colleen Scanlon (American Nurses Assn.; Catholic Health Initiatives); John Mahoney (National Hospice Organization); Richard Fife and Melanie Merriman (Vitas); Gretchen Brown (Hospice of the Bluegrass); Charles Sabatino (American Bar Assn.)
1996 May NY forum on SUPPORT -- Hastings Center, Callahan
1996 May American Academy of Hospice Physicians (a spin-off of the International Hospice Institute) becomes American Academy of Hospice & Palliative Medicine (AAHPM) in 1996.  AAHPM helps launch the American Board of Hospice and Palliative Medicine (ABHPM), which incorporates in May, 1996.  ABHPM becomes the palliative care certification agency.  It administers its first certifying exam later that year.
1996 Jun

Public engagementProject 2010 ("Five Wishes;" in Florida) is launched with a grant of $398,000 from RWJF to James Towey's Commission on Aging with Dignity.  This project is credited with inspiring the creation of Community-State Partnerships (below), headed by Midwest Bioethics.

The year 2010 is (roughly) the year in which Baby Boomers will begin reaching the age of 65 (and going on Medicare).  Five Wishes is a type of advance directive that is loosely worded in comparison to many other advance directive forms, and which encourages discussion about a person's "wishes" for his or her end of life decisions.

1996 Jul

Institutional changeRWJF awards $297,000 grant to the Center for Applied Ethics and Professional Practice (CAEPP) at the Education Development Center (EDC) in Massachusetts, to convene the National Task Force on End-of-Life Care for Patients in Managed Care, "23 experts in health care policy, managed care, geriatrics, long-term-care, bioethics, palliative care, medicine and nursing, and hospice."  The Task Force convened in three times during 1997, and reviewed surveys from "all managed care organizations in the United States providing capitated services to Medicare enrollees."

In May, 1999, the Task Force would produce a widely publicized report, Meeting the ChallengeTwelve Recommendations for Improving End of Life Care in Managed Care.

Steering committee: Steven Miles, Bruce Jennings, and Mildred Solomon (EDC); committee members included Ira Byock, Joanne Lynn, Kathleen Foley. 

[Next:  Meeting the Challenge  is published and five managed care firms are on board.]

1996 Aug Last Acts moves forward. RWJF president Dr. Steven Schroeder sends "Dear Colleague" letter to approximately 140 organizations to recruit Task Force members for Last Acts. Task forces: Family; Palliative Care; Service Providers; Provider Education; Financing; Workplace. Resource committees: Communications, Diversity, Spirituality, Standards & Guidelines, and Evaluation & Outcomes.
1996 Aug

IOM's Conference on Measuring Care at the End of Life, held August 27 at Wood's Hole, developed guidelines. Produced a draft "toolkit" to measure quality of care, but the toolkit is a compendium of surveys to measure the patient's status, from overall "quality of life," to "spirituality." Ira Byock's "Missoula-Vitas Quality of Life Index" was one of the quality of life instruments in the toolbox.

Teno directed; Lynn was a presenter. Byock attended. RWJF & Cummings funded $100,000.

1996 Sep

On 9/24, Rep. Ralph Hall (D-TX) introduces Assisted Suicide Funding Restriction Act (HR 4149); and in the Senate,  Sen. Byron Dorgan (D-ND) introduces the same bill S. 2108; (104th Congress).  Both HR 4149 and S 2108 contained the following proviso:

Nothing in this Act, or in an amendment made by this Act, shall be construed to create any limitation relating to--

  1. the withholding or withdrawing of medical treatment or medical care;
  2. the withholding or withdrawing of nutrition or hydration;
  3. abortion; or
  4. the use of an item, good, benefit, or service furnished for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as such item, good, benefit, or service is not also furnished for the purpose of causing, or the purpose of assisting in causing, death, for any reason.

The bills were introduced again in the 105th Congress, this time with Ashcroft (R-MO) as co-sponsor of the Senate bill.  The bill would become law in April, 1997.

1996 Oct

Institutional changeCongress of Clinical Societies: Conference on the Ethics of Managed Care (fourth in a series that began in 1987); held on October 7.

"The conference brought together leading scholars in medical ethics, health policy, law, and medicine with representatives of the managed care industry to discuss how the integrity of medical practice could be maintained and strengthened in managed care settings during a time of dramatic change in the health care delivery system." [ ]

Joseph J. Fins organized the conference; Speakers included Joanne Lynn and Daniel Callahan.
Hosted by American Geriatrics Society and Hastings Center.
Funding: RWJF grant #28153 for $49,000 to American Geriatrics Society.

1996 Nov

November 23: IOM's Committee on Care at the End of Life" - Public Hearing #2, at National Academy of Sciences, Irvine, CA  (developing futility guidelines; led to publication of  "Approaching Death" in June, 1997)   Again led by Christine Cassel; panelists included:  Alicia Super, RN (Supportive Care of the Dying); Richard Della Penna,  MD (Kaiser Permanente); Betty Ferrell (City of Hope National Medical Center); Steven Miles (U. of Minn. Center for Bioethics); Susan Tolle (Oregon Health Sciences Univ.); Neil Wenger, M.D. (UCLA Medical Center Ethics Committee).


[back] [next]

Updated on September 22, 2009 7:08
Unpublished work © Copyright 2004-2009  I. Whitlock.