Oregon's Low In-Hospital Death Rates: What Determines Where People Die and Satisfaction with Decisions on Place of Death?

Oregon's Low In-Hospital Death Rates: What Determines Where People Die and Satisfaction with Decisions on Place of Death?

Susan W. Tolle, MD;
Anne G. Rosenfeld, PhD, RN;
Virginia P. Tilden, DNSc, RN; and
Yon Park, BA

From Oregon Health Sciences University, Portland, Oregon.

Abstract

Where Americans die is much more influenced by what part of the country they live in than by what their preferences are for location of death. Although most Americans report a preference for death at home, a majority still die in acute care hospitals. We describe the experiences of patients who died in Oregon (the state that currently has the lowest in-hospital death rate in the United States—31%) and the views of their families. We examine the factors influencing respect for dying patients' preferred location of death.

Data from Oregon studies confirm that decisions to avoid hospital admission are far more common than discharge of the actively dying. Do-not-resuscitate orders were reported for 91% of nursing home residents in one study and living wills were reported for 67% of a random sample of adult Oregon decedents in a second study. In the second study, decisions not to start treatment were far more common than decisions to stop treatment (79% compared with 21%). Only 2.4% of families reported that “too little” treatment was given.

Throughout the United States, use and availability of beds in acute care hospitals have been confirmed to be the principal determining factors in location of death. Within that constraint, however, the availability of other resources and services both facilitates the process of arranging for patients to die outside the hospital and improves satisfaction with the quality of terminal care.

Article and Author Information

Acknowledgments: The authors thank Elizabeth (Ireland) Mitchell (Administrative Director of the Center for Ethics in Health Care) and Marina Rios-Daley (Administrative Coordinator) for their assistance with this project and Christine Nelson (Research Associate) for assistance with POLST data.
Grant Support: In part by the Greenwall Foundation, the Meyer Memorial Trust, the Project on Death in America, the Nathan Cummings Foundation, and the Robert Wood Johnson Foundation. The views expressed are those of the authors and do not necessarily represent those of the funding agencies.
Requests for Reprints: Susan W. Tolle, MD, Center for Ethics in Health Care, UHN-86, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098.
Current Author Addresses: Dr. Tolle: Center for Ethics in Health Care, UHN-86, Division of General Internal Medicine, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098.
Dr. Rosenfeld: Center for Ethics in Health Care, School of Nursing, SN-5N, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098.
Dr. Tilden: Center for Ethics in Health Care, School of Nursing, SN-ORD, Oregon Health Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201-3098.
Ms. Park: Center for Ethics in Health Care, School of Medicine, L-311, Oregon Health Sciences University, Portland, OR 97201-3098.