Improving Care at the End of Life

A program in Oregon addressed the end-of-life problem by going to the root of the issue—asking patients’ specific wishes in advance and enforcing their decision. The percentage of patients who died in the hospital rather than at home in Oregon in 1999 was the lowest in the nation at thirty-one percent; the national average was fifty-six percent.(1)

Oregon’s plan was straightforward but it did not happen overnight.(2) In 1991 a statewide group of ethics committees concluded that Oregon residents shared the ubiquitous American problem of dying. The task force determined that it was not so hard to determine who was nearing the end of life—patients in nursing homes and the frail elderly with multiple chronic conditions. What was needed was standard hospital orders filled out ahead of time and signed by a physician or nurse practitioner that specified exactly the limits of treatment when a patient entered a hospital. The state Medicaid program paid doctors to meet with patients and their families in a quiet office setting and discuss just how far they wanted doctors in hospitals to go should they require hospital admission. Some did not want hospital admission at all unless their pain could not be controlled. A standard set of orders was devised by the committee and piloted. The orders were completed and signed by the doctor or nurse practitioner in the patient’s presence. The orders specified, for instance, whether the patient wanted cardiopulmonary resuscitation, intravenous fluids, ventilators, antibiotics, or nutritional support. Nothing was left to any doctor’s imagination. The orders (called Physician Orders for Life-Sustaining Treatment or POLST) were to accompany any patient likely to be near the end of life that was transferred or discharged from a nursing home or home.

After five years of refinement the concept was tested statewide in eight long-term care facilities. The results were remarkable. No patient received unwanted cardiopulmonary resuscitation or artificial ventilation. Of 183 patients in the statewide test, twenty-four were hospitalized only because the nursing homes could not control suffering. For the others, the nursing homes could fulfill the patients’ medical orders.

Before statewide implementation, Oregon law was changed to protect emergency medical service providers who followed the POLST orders in the field--for instance, protecting them from litigation should they not provide cardiopulmonary resuscitation in compliance with a patient’s POLST orders. The orders were made bright orange so that no one could miss them and the public was extensively educated.

As a result, Oregon has reported the lowest rate of Medicare in-hospital expenditures in the last six months of life--for example, $6,198 per enrollee in Bend, Oregon, versus $17,797 in New York City.(3)

1. Susan W. Tolle and Virginia P. Tilden, “Changing End-of-Life Planning: The Oregon Experience,” Journal of Palliative Medicine 5, no. 2 (April 2002): 311-317.
2. Ibid.
3. Ibid.