Lessons from Oregon in Embracing Complexity in End of Life Care

Article published in the New England Journal of Medicine discusses the development of POLST along with other health care initiatives as the likely reason Oregon patients receive care more consistent with their own end-of-life wishes, compared to Washington state and the U.S. as a whole.

In a March 16, 2017 New England Journal of Medicine article, Lessons from Oregon in Embracing Complexity in End of Life Care, Susan Tolle, MD, and Joan Teno, MD, discuss why Oregon patients are more likely to receive the end-of-life heath care treatment they want, compared to patients in Washington and the U.S. overall.

Persons dying in Oregon are “less likely to be hospitalized and more likely to use hospice services at home” than are those in Washington state and in the U.S. overall in three ways: (1) Oregonians are more likely to die at home (about 66% of Oregonians vs. about 40% of Americans elsewhere); (2) Oregonians are less likely to utilize the intensive care unit (ICU) in their final 30 days of life (18.2% in Oregon vs. 23.0% in Washington and 28.5% in the rest of the U.S.); and (3) if hospitalized in the last month of life, Oregonians are more likely to be discharged home (73.5% in Oregon vs. 63.5% in Washington and 54.2% in the rest of the U.S.).

Tolle and Teno acknowledge it is “difficult” to determine the exact causes behind the differences in end-of-life care outcomes in Oregon and the rest of the country, but suggest that it is due to not only the presence of a strong POLST Paradigm Program, but many initiatives developed in coordination with their POLST Program.

End-of-life care in Oregon has been actively developed to become strongly patient-centric, due to many measures that support POLST. These are complex and far-reaching, and have been developed with the purpose of ensuring that patients’ end-of-life treatment wishes will be not only documented but effectively honored, which takes much more awareness and system-wide support. Some of the additional initiatives that support POLST in Oregon include: public and professional education, legislation that established that POLST medical orders must be honored by EMS professionals in the field, support from the Oregon Medical Board (for POLST being honored across all care settings, even those at which the signing physician does not have admitting privileges), and effective EMR integration (immediate visibility and accessibility in electronic medical recordkeeping systems). Local champions, media engagement, quality tracking (to improve the system and prevent unintended consequences), and a stable financial base for the POLST Program are important, in addition.

The authors underscore the fact that POLST is much more than a form and that a successful POLST Paradigm Program requires long-term, dedicated effort in developing a complex, multifaceted systems approach that supports it.

View original publication online (limited access).

View reprint as NEJM catalyst article (freely accessible).