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Ensuring patient autonomy in the medical treatment process, particularly in decisions involving death and dying, made a major stride with the implementation of the Patient Self-Determination Act in 1991. Compliance with the act was not difficult in terms of providing information and education for patients and providers. However, role comfort for professional staff, as well as complex issues involving the activation process, still are of major concern. The author reports 4 years of implementation experience of chief nurse executives.