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Editorial: We're dying more at home. That's good

Editorial: We're dying more at home. That's good

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For many years now, pollsters have asked Americans where they would rather die, in home or in a hospital.

Once the initial shock of the question wears off ("Who said I was going to die in the first place? How dare you!"), most of us answer that we would prefer to die at home, in familiar settings, surrounded by loved ones. It makes sense.

Then, of course, most Americans go off and die in the hospital, in large part because they haven't made their end-of-life wishes known to people who might have to make those decisions. (Or, in the alternative, because they haven't thought that much about their end-of-life decisions in the first place.)

Oregon is an exception. And that's a good thing. 

A recent article in The New England Journal of Medicine noted that nearly two-thirds of Oregonians who died in 2013 did so at home, as opposed to 39.6 percent of Americans. (The article relied on statistics from Medicare and defined "home" as wherever the person was living at the time of death.)

The article, by Dr. Susan W. Tolle, head of the Center for Ethics at Oregon Health & Science University, and Dr. Joan M. Teno of the University of Washington, had other good news for Oregon residents who might die someday:

• The rate of intensive care unit use in the last 30 days of life in Oregon was 18.2 percent, as compared with 23 percent in Washington state and 28.5 percent in the rest of the United States.

• Patients who were hospitalized in the last month of life were more likely to be discharged to their homes in Oregon (73.5 percent) than in Washington (63.5 percent) or in the rest of the United States (54.2 percent).

These numbers likely will not surprise anyone who's followed Oregon's efforts to lead the way in the tricky issue of end-of-life care. In their article, Tolle and Teno argue that one big step forward came in 1995, when Oregon created a POLST program.

POLST is an acronym for Physicans Orders for Life-Sustaining Treatment; the program essentially allows patients to document their preferences regarding the use of life-sustaining treatment. Ideally, medical providers have access to a patient's POLST documents and abide by their instructions.

But just having a POLST program in place is not enough, the article notes: After all, Washington state has a similar program, but it trails Oregon in some of the metrics that Tolle and Teno were tracking.

The difference between the two states? At the risk of oversimplifying, a lot of it comes down to execution and follow-through. 

In the decades since Oregon adopted the POLST program, the state has developed educational materials about it, organized conferences to spread the word, researched the issue and (perhaps most importantly) maintained a statewide registry of POLST participants. That electronic registry allows medical providers throughout the state to access it to check on a patient's wishes at the end of life; that's important because those patients may not always be able to speak for themselves.

Washington had a registry in place, but abandoned it because it wasn't widely used. 

Oregon's POLST system isn't perfect: For example, Tolle and Teno note that one-click access to the POLST form from a patient's electronic medical records is not yet available in most hospitals. We need to keep measuring our progress and improving our systems.

Perhaps the best part of filling out the POLST forms is that it provides a starting point for conversations that are easy to put off. No one likes talking about death. But talking about it now might help ensure that we can die on our own terms. (mm)


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