Policy Statement: Decisions near the End of Life
August 1994 November
1999 (revised) November
2004 (revised) November
STATEMENT OF THE ISSUE
End-of-life decision making and care are important aspects of the delivery of healthcare. Medical technology has shaped the circumstances of death, giving us options that may impact when, where and how we die. Intervening at the moment of death, technology can now sustain lives even when there is little or no hope for recovery or a meaningful existence. However, such actions may be inconsistent with patient desires and foster unwarranted variations in end-of-life practice patterns.
In response, patients and/or their proxies are exercising more influence over decisions regarding interventions that may prolong existence rather than allowing the natural progression of the dying process near the end of life. The traditional value to preserve life by all possible means is now being weighed against patient-centered, quality-of-life considerations based on evidence-based care and a shared decision-making process.
The American College of Healthcare Executives (ACHE) urges healthcare executives to address the ethical dilemmas and care issues surrounding death and dying. Additionally, executives should promote public dialogue that will lead to awareness and understanding of end-of-life concerns.
ACHE encourages all healthcare executives to play a significant role in addressing this issue by:
Ensuring Ethical End-of-Life Decision Making
* Healthcare executives and their organizations should promote the patient's (or, when lacking decision-making capacity, the authorized surrogate's) self-determination regarding end-of-life decision making. Generally, informed adult patients or their surrogate have the ethical and legal right to accept or refuse any recommended treatments based on the ethical principle of autonomy. Such decision making should include an open, truthful discussion regarding the patient's situation and evidence-driven healthcare options.
* The healthcare executive should ensure that patient or surrogate decisions are appropriately documented and respected.
* When there is disagreement regarding treatments for patients lacking decision-making capacity (even those patients who have valid advance directives or durable power of attorney documents), the guidance of an ethics committee or similar resource may aid in resolution. Healthcare executives should ensure that there are clear guidelines, including a process to address care management disputes as well as provide support to healthcare professionals and families responsible for making treatment choices.
Fostering the Use of Advance Planning Documents
* Healthcare executives should advocate for the introduction, discussion and completion of organ and tissue donation designation and advance directives documents, including a recognized living will and durable power of attorney for healthcare. Ideally, such documents should be prepared prior to hospitalization or a medical crisis (see the related Policy Statement, "Organ/ Tissue/Blood/Blood Stem Cells Donation Process," atwww.ache.org/policy/ organ.cfm).
* When the patient lacks decisionmaking capacity, treatment decisions should conform to what the patient would want based on his or her written or oral advance directive. …