END-OF-LIFE: Why Do So Few Oregonians Die in Hospitals?
Although the availability of acute-care hospital beds has long been thought to be the determining factor in where a patient dies, a group of researchers argue in the current Annals of Internal Medicine that other factors -- such as alternative care resources and economic forces -- play a larger role and that where Americans die may be largely influenced by where they live. Portland, OR, has 1.9 hospital beds per 1,000 residents, "remarkably low" on the national range of 1.6 to 5 beds per 1,000. Not surprisingly, the state's in-hospital mortality rate has always been low. But in the past several years it has sunk still farther; from 50% in 1980 to 35% in 1993, when the national rate was 56%. Today, just 31% of Oregonians die in the hospital -- the lowest rate in the nation.
Because They're Prepared ...
Dr. Susan Tolle and colleagues at the Oregon Health Sciences University determined that for Oregon patients, "decisions not to start treatment [are] far more common than decisions to stop treatment (79% compared with 21%)." Similarly, terminally ill patients' decisions to avoid admission to a hospital are more common than discharge of the actively dying -- "usually because [patients] prefer to die at home or in the nursing home if they have been a long-term resident." Most Oregon patients, it would seem, are well equipped to make decisions in the final days of life: a study of deaths among nursing home residents found 91% had requested do-not-resuscitate orders. Similarly, "a random sample" of deceased patients' families found that 67% had prepared living wills.
.. And Because They Have Other Choices
The authors suggest some reasons besides preparedness for the state's low hospital death rate: First, Oregon is one of "the top four states in hospice penetration in the United States." In 1997, approximately 30% of Oregon residents who died did so under hospice care. The state also has a strong adult foster care program; 5% of decedents die under foster care. The authors conclude, "Many factors probably contributed to Oregon's culture in care of the dying," including the state's resource allocation and work to "educate the public about the right to make choices in end-of-life care" (Tolle et al., 4/20 issue).