Inevitably there are some omissions m such a document and many of the symptoms of patients with ALS are not addressed m this first document but will be taken up m future iterations. Of particular importance m the document is the evidence-based recommendation about the value of percutaneous endoscopic gastrostomy and the importance of timmg m presentmg this option to patients. Similarly, strong evidence-based recommendations are made about the utility of noninvasive mechanical ventilation and the beneficial impact that this has on symptoms of hypoventilation and on survival. Finally, management of patients m the termmal phase of the disease usmg the highest standard of palliative care is discussed m some detail. Perhaps one of the most important contributions of this document is the highlighting of areas where further research is needed. This has been done m each of the major sections of the paper. More rigorous clinical investigations are still needed to help answer some of the most pressmg management issues for patients with ALS. Mission Statement The Quality Standards Subcommittee of the American Academy of Neurology (AAN) is charged with developmg practice parameters for physicians. This evidence-based review addresses some of the major management issues m patients with amyotrophic lateral sclerosis (ALS), and highlights the many areas where more research is needed.