map of states colored by degree of POLST adoption
To the Better End

Reports on the States

State laws lag medical realities 


Fred Hansen
Winter '07
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backlink arrow (up and to the right)Physpics


Given the relative speeds of innovation in medicine and legislation, it should come as no surprise that the legal climate and medical practice are inconsonant with the medical possibilities.

There has been progress. When this page was first written only three states had adopted the POLST model document, Oregon, New York, and West Virginia. Now (2014) as shown above left in shades of pink, POLST has been endorsed by sixteen states and is in-process in all but eight of the rest.


State grades

Robert Wood Johnson Foundation logo
http://www.rwjf.org/files/publications/other/meansbetterend.pdf

The Robert Wood Johnson Foundation sponsored a program which, among much else, graded the US states on their treatment of end-of-life. Pennsylvania got a below average grade.

Pennsylvania is about average, but with a D grade.  I've compiled this table from their data. It  color codes the grades from blue for A down to purple for E. The PA grade is shown with this color coding, Then the distribution of grades among the sates is shown, with the modal grade highlit in the color coding. The last column compares the PA grade to the modal grade. Here we find that PA  has the modal grade in  8 of the 12 categories. What I found striking was that in more than half of the categories no state rated an A grade. And in a third of categories, no state got a B.


 

PA

A

B

C

D

E

PA vs Mode

Advance directive laws

E

7

13

17

10

4

– –

Deaths at home, 1997

D

0

0

7

43

1

=

People over 65 who used hospice in the last year of life, 2000

D

0

1

10

38

2

=

Median number of days in hospice, 2001

D

0

0

6

40

1

=

Hospitals reporting pain management programs, 2000

C

0

6

25

17

3

=

Hospitals reporting hospice programs, 2000

D

0

0

3

26

23

=

Hospitals reporting palliative care programs, 2000

D

0

0

2

10

39

+

People over 65 with 7 or more ICU days (last 6 mos. of life), 2000

C

5

10

21

10

5

=

Nursing home residents in persistent pain, 1999

C

0

1

39

10

1

=

Strength of state pain policies, 2001

B

7

9

12

13

10

+ +

Percentage of general primary care and primary care subspecialty physicians who are certified in palliative medicine, 2000

D

5

9

21

8

7

Percentage of full-time-equivalent nurses (estimated) who are certified in palliative care, 2000

C

5

10

20

11

5

=



PA Brief
PA Full Report

two dancing golden-agers

http://www.aging.state.pa.us/aging/lib/aging/DOA-102forweb.pdf
http://www.aging.state.pa.us/aging/lib/aging/DOA-task_force_long_report_final_2007_2.pdf

Pennsylvania's Department of Aging commissioned a report on improving end-of-life experiences. The brief and full versions are cited at the right.

The summary states the task force's primary goals:
■ To create momentum for change in policy, systems, and grassroots community activity to reform and improve palliative
and end-of-life care;
■ To mobilize stakeholders in the public and private sectors for action by providing them with information and pathways toward
reform of palliative and end-of-life services and care;
■ To energize local citizen action groups throughout the state to organize and create change around palliative and end-of-life care.

They go on to say:
In sharp contrast to 1900, when acute infections constituted the leading causes of death, today most people die from chronic progressive illnesses. The cumulative effects of these illnesses on individuals and their families present an increasingly urgent challenge for our health care delivery system ... . all require action by providers and policy makers to address issues associated with serious illness and the need for improved palliative and end-of-life care.
Basically, people are staying alive to older ages and the health care system has not adapted. Pain is not managed well. Hospitals are used where less expensive alternatives would be more pleasant and more suitable. Laws inhibit adoption of new policies.


In all, the task force produced 160 recommendations in these categories:

Advance Directives

 
  1. The definition of terminal illness is too strict. Under current law, an advance directive becomes operative only when the patient has been diagnosed as permanently unconsciousness or terminally ill. Although consensus was not achieved on this point, some Task Force members believe that these criteria are too strict, with the result that the wishes of people with advance directives are not followed because their condition is judged to fall outside those narrow parameters.
  2. When there is no advance directive, the surrogate’s authority is ambiguous.
  3. Advance directives and Do-Not-Resuscitate orders are limited in portability.
  4. Members of the Disabilities and Minority Communities have deep concerns regarding advance directives and DNR orders.

Recommendations
- improved, more supportive policies
- greater awareness
- continuity across care settings

Provision of Palliative Care

  Palliative care is patient- and family-centered care that optimizes
quality of life by anticipating, preventing, and treating suffering. ...
New national initiatives standardize the practices of palliative care: The National Consensus Project for Quality Palliative Care (NCP) and the National Quality Forum's (NQF) Framework and Preferred Practices for a Palliative and Hospice Care Quality Project.

Recommendations
- create a web-based statewide clearinghouse for palliative care
- for a medical license, require evidence of baseline education in palliative care
- increase funding for scholarships
- offer incentives for advanced training in palliative care
- adopt the Model Guidelines for the Use of Controlled Substances for the Treatment of Pain
- A single state agency should oversee compliance with the national standards

Financing Care

  Medicare currently spends 27% of its total dollars on people who
are in their last year of life. About 70% of people who die each
year are covered by Medicare, with about 13% also covered by
Medicaid. Coverage biased toward hospital stays, which are more expensive than appropriate alternatives.

Recommendations
- explore new models of care delivery through demonstration projects that focus on redistributing and realigning incentives to provide patient-centered care and quality of life rather than incentives for over-treatment and lengthening of life at all costs.
- reverse policies that restrict people on the Medicare hospice benefit from also receiving home-based services
- invest in palliative care programs and integrate them into routine care

Special Populations

  Populations with particular concerns include: older adults, children, racial-ethnic minorities, people with disabilities, rural populations, and prison populations.
- need appropriate safeguards for all

Professional Education

  Inadequate professional palliative and end-of-life education
- educational reform is needed


Raising Awareness in the Community

  Need to improve the public's understanding of palliative care and the end-of-life experience. Especially in regards to
- dying in the context of significant personal relationships
- support for the lay caregiving experience
- hospice and palliative care
- pain and symptom management

Research, Measurement, and Data

  - need improved systems for research, analysis, measurement, and tracking of efforts in palliative and end-of-life care
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