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In 1995, the Hospital Ethics Committee Consortium organized by Midwest Bioethics Center created the PATHWAYS to Patient-Centered Palliative Care: A Community Approach--a guideline document, or "how to" manual for hospitals that want to improve care of the seriously ill and dying. Following the publication and wide dissemination of this manual, the Center began to implement strategies to produce positive change in the way hospitals respond to dying persons and their families. Spurred by the same desire to alter hospital culture through improved care of the dying, eleven hospitals collaborated with the Center to form the PATHWAYS Hospital Project.

As part of Midwest Bioethics Center's PATHWAYS to Improve End-of-Life Care project, we conducted an exploratory study in the Latino community of Kansas City to understand health beliefs, practices, and values, particularly as they relate to end-of-life care. We conducted ten focus groups and interviewed more than seventeen individuals who serve the Latino community in a social service, ministry, or health care capacity. We found that people were very concerned with "barriers to health care" (our term), and very willing to reveal their preferences for health care decision making and end-of-life care treatment options. We believe that bioethicists should conduct other, similar projects because they can improve our engagement with the Latino population and help Latinos find a greater voice in health care settings.

Midwest Bioethics Center believes that encouraging palliative care training in the school milieu is one of the keys to achieving lasting improvement in end-of-life care. Therefore, a cooperative venture to increase palliative care education in medical schools was among the first strategies envisioned in the Center's PATHWAYS initiative. Its implementation, no less than its goal, requires both time and effort.

The Midwest Bioethics Center's Nursing Leadership Institute 1999 focused on leadership in ethics and end-of-life care. Twenty-four nurses attended the four-day retreat, during which national speakers, community experts, and Center staff facilitated the continuing education of nurse leaders dedicated to improving end-of-life care in their communities. All participants in the Institute agreed to design and implement a community project for their constituency. Project reports will be made prior to the next nursing leadership institute. This article examines the role of nurses in providing end-of-life care.

Midwest Bioethics Center responded to the SUPPORT study with a strategic initiative called PATHWAYS to Improve End-of-Life Care: A Community Approach. This article introduces that initiative and reviews its substantial contributions in the broad sense. The effects of this program, although its evaluation has yet to be completed, are far-reaching because PATHWAYS tackled the problem of dying, not as a medical problem, but as a problem for the community as a whole.

The principle of autonomy anchors decision making for most North Americans. For people with disabilities, however, the quest for self-determination is often countered by society's responsibility to take care of those who have some area of weakness or incompetence. Those who serve this population must, therefore, intentionally shift the balance of power to encourage independent living and to give people with disabilities a voice in their own lives. Changes in the system of care, training, and the way questions of competency are adjudicated are contemplated.