Nurse Practitioners Fill Gap by Providing Timely Help in Recording End-of-Life Treatment Wishes

  • OHSU study published in the Journal of Palliative Medicine
    found that in Oregon, nurse practitioners completed nearly 25,000, or
    11 percent, of Physician Orders for Life-Sustaining Treatment (POLST)
    forms, in the past six years
  • 3 of 19 states with established POLST programs don’t permit nurse
    practitioners to execute forms, making access inconsistent

PORTLAND, Ore. & DUARTE, Calif.–(BUSINESS WIRE)–Not all states allow nurse practitioners to make a patient’s treatment
wishes part of their medical record, yet a six-year study concludes that
they can improve seriously ill patients’ access to advance-care
planning. Nurse practitioners often serve as the primary care provider
or a member of the team caring for patients in last months of their
lives when they are most likely to seek end-of-life treatment counseling.

The study — led by OHSU in Portland, Oregon, and published in the Journal
of Palliative Medicine
today — found that nearly 25,000, or about 11
percent, of the Physician Orders for Life-Sustaining Treatment (POLST)
forms submitted between 2010 and 2015 in Oregon were completed by an
advanced practice registered nurse. Nurse practitioners have been
empowered to enter forms in the Oregon POLST Registry since 2001, making
the state an ideal test case for their impact.

Out of 19 states with established POLST and similar programs, three —
Georgia, Louisiana and New York — do not currently authorize nurse
practitioners to sign patients’ forms.

“It is vital that the next generation of physicians honor and champion
the role that nurse practitioners play in patient-centered care at the
end of life,” said Sophia Hayes, a third-year student in the OHSU School
of Medicine, who led the study.

Hayes, in her analysis of the data, adds that the inclusion of nurse
practitioners in the POLST process is increasingly important as the
number of physicians and physician assistants trained in hospice and
palliative medicine is inadequate to meet the needs of the aging

Study co-author, Betty Ferrell, Ph.D., concurred. “Nurses are an
untapped resource to enhance communication of patient values and
preferences through POLST.” Ferrell is a nurse and researcher at City of
Hope, a world-renowned comprehensive cancer treatment and research
center in California, and director of the End of Life Nursing Education
Consortium (ELNEC), a national training program for nurses.

In Oregon, nurse practitioner involvement in POLST has slowly risen.
Nine percent of POLST forms were signed by nurse practitioners in 2010;
by the end of 2015, nurse practitioners executed 11.9 percent of all new
forms in the state. In the six-year period from 2010 to 2015, nurse
practitioners signed 24,620 of the 226,101 forms completed in Oregon;
physicians signed 85.3 percent of these forms and 3 percent were signed
by physician assistants. This data was culled from the Oregon POLST

A study published last year by OHSU research team member Dana Zive,
M.P.H., showed that POLST orders are completed a median of six weeks
prior to death. Timing is important. For many patients their goals may
change abruptly as they near the end of their lives. Providing access to
a professional skilled in having these conversions at the right time —
often as the patient gets sicker and wants to explore options to protect
the quality of their final weeks — requires tapping the talents of all
of the health care professionals involved in the patient’s care.

“Advocacy from physician leaders is critical to overturning state laws
and regulations that prohibit nurse practitioners from signing POLST
forms,” said Susan Tolle, M.D., a professor in the OHSU School of
Medicine and chair of the Oregon POLST Program. Tolle provided testimony
to the Oregon Medical Board and coordinated physician advocacy that
resulted in Oregon’s regulatory change in 2001, which expanded the POLST
program to nurse practitioners.

The National POLST Paradigm Task Force recommends that physicians,
physician assistants and nurse advanced practice registered nurses be
permitted to execute POLST forms. This recommendation is also supported
by new Centers for Medicare and Medicaid Services billing codes as part
of its goals of care counseling reimbursement.

Forty-seven states are either developing or have already endorsed POLST
programs; 19 have established programs, though the program name (e.g.,
MOLST or POST), structures and policies differ slightly by state.
California and West Virginia recently changed their policies to allow
nurse practitioners to sign the treatment directive forms.


Hayes and Ferrell report no financial interests or potential conflicts
of interest. Zive reports salary support as the Director of the Oregon
POLST Registry, which operates at OHSU under contract with the Oregon
Health Authority. She serves as a Senior Scholar with the Center for
Ethics in Health Care at OHSU, as well as the Oregon POLST Task Force
Research Liaison. She is a member of the National POLST Paradigm Task
Force (NPPTF) Research Committee and is currently the technology advisor
for the NPPTF. Tolle reports grants from California HealthCare
Foundation, The Retirement Research Foundation, and the Archstone
Foundation, during the conduct of the study. Tolle chairs the National
POLST Paradigm Task Force Research Committee, the Oregon POLST Task
Force, and directs the OHSU Center for Ethics in Health Care, which
serves as the administrative home of both the National POLST Paradigm
and Oregon POLST Programs. The OHSU Center for Ethics in Health Care
does not accept funding from healthcare industry sources.

About OHSU

Health & Science University
is a nationally prominent research
university and Oregon’s only public academic health center. It serves
patients throughout the region with a Level 1 trauma center and
nationally recognized Doernbecher Children’s Hospital. OHSU operates
dental, medical, nursing and pharmacy schools that rank high both in
research funding and in meeting the university’s social mission. OHSU’s
Center for Ethics partners with practitioners of all health professions
regionally and nationally to be a leading voice for compassionate health
care. OHSU’s Knight Cancer Institute helped pioneer personalized
medicine through a discovery that identified how to shut down cells that
enable cancer to grow without harming healthy ones. OHSU Brain Institute
scientists are nationally recognized for discoveries that have led to a
better understanding of Alzheimer’s disease and new treatments for
Parkinson’s disease, multiple sclerosis and stroke. OHSU’s Casey Eye
Institute is a global leader in ophthalmic imaging, and in clinical
trials related to eye disease.


The Physician Orders for Life-Sustaining Treatment Paradigm, or POLST (,
was developed by Oregon health care professionals in 1991 in an effort
to ensure the wishes of those with advanced illness or frailty are
followed. POLST programs have been adopted or are in development in 47
states across the country; 19 states have established programs. The
Oregon POLST (
Registry was created and funded by the Oregon Legislature through the
passage of House Bill 2009 on July 1, 2009. The legislation created the
registry within the Oregon Health Authority (OHA). The registry is
contractually operated for the OHA by the Department of Emergency
Medicine at OHSU.

About City of Hope

City of Hope is an independent research and treatment center for cancer,
diabetes and other life-threatening diseases. Designated as one of only
47 comprehensive cancer centers, the highest recognition bestowed by the
National Cancer Institute, City of Hope is also a founding member of the
National Comprehensive Cancer Network, with research and treatment
protocols that advance care throughout the world. City of Hope is
located in Duarte, California, just northeast of Los Angeles, with community
throughout Southern California. It is ranked as one of
“America’s Best Hospitals” in cancer by U.S. News & World Report.
Founded in 1913, City of Hope is a pioneer in the fields of bone
marrow transplantation
, diabetes
and numerous breakthrough cancer drugs based on technology developed at
the institution. For more information about City of Hope, follow us on Facebook,
or Instagram.

Media Toolkit

Download photos of Sophia Hayes, Susan Tolle and Betty Ferrell as well
as a video of Hayes and Tolle on OHSU News.

Related Content



Center for Ethics

of Hope


Elisa Williams, 503-494-8231
of Hope
Denise Heady, 626-218-8803