Medical technology has shaped the circumstances of death, giving us options about when, where and how we die. Intervening at the moment of death, technology can now sustain lives, but often there is little or no hope for recovery or for a meaningful existence.

Fearful of economic dependency, prolonged pain and loss of self, patients and/or proxies are exercising more influence over decisions near the end of life. The traditional value to preserve life by all possible means is now being weighed against quality-of-life considerations.

The American College of Healthcare Executives (ACHE) urges healthcare executives to address the ethical dilemmas and problems surrounding death and promote public dialog that will lead to awareness and resolution of death with dignity concerns.

ACHE encourages all healthcare executives to play a significant role in addressing this issue:

• Executives should heighten awareness of ethical issues surrounding the right to choose treatment through information forums that promote open discussion among patients and their families, attorneys, clergy, journalists, physicians, and other healthcare professionals. By raising moral and ethical questions, healthcare executives will aid the public in understanding the growing impact of technology on death and dying.
  
  
• Healthcare executives should advocate the completion of advance directives, including living wills and durable powers of attorney for healthcare. Ideally, such documents should be prepared prior to hospitalization or medical crisis.
  
  
• These and similar legal mechanisms encourage people to consider under what circumstances they would not want certain life-prolonging treatments. Use of a power of attorney or laws that permit the appointment of a proxy have the added advantage of allowing individuals to designate a specific person who would make treatment choices for them at any time they lack decision-making capacity. The ultimate objective of advance directives is to protect the rights of patients to influence clinical decisions affecting their care.
  
  
• Healthcare executives have a responsibility to ensure their organizations provide support for patients and their families as treatment decisions are reached. Patient autonomy (the right of an individual to influence decisions affecting his or her treatment) should remain at the core of this process.
  
  
• When there is disagreement on treatment for incompetent patients (even those patients who have valid advance directives or a durable power of attorney), the guidance of an ethics committee or similar resource may aid in resolution. Healthcare executives should develop clear guidelines to handle disputes and provide support to physicians and families responsible for making treatment choices.
  
  
• When developing and implementing guidelines, healthcare executives must encourage cooperation and understanding of ethical decision making among members of the governing body, executive management, physicians and other members of the healthcare team. Executives should work to develop methods of raising awareness and providing education regarding sensitivity to ethical dilemmas.
  
  
• If organizational policies limit end-of-life options for patients and families, healthcare executives have a responsibility to see that mechanisms are in place that provide disclosure of such limitations.
  
  
• Executives should support the development of resources and programs that promote pain control as a crucial modality in the management of patients at the end of life.
  

Healthcare executives must foster reasoned, compassionate decision making that considers the rights and values of patients and staff. While interpretation of these principles will vary by local custom and law, healthcare executives have a responsibility to ensure their organizations operate with respect for the inherent worth and human dignity of every individual.

Approved by the Board of Governors of the American College of Healthcare Executives on November 8, 2004.