Nurse practitioners fill gap by providing timely help in recording end-of-life treatment wishes

10/21/16  Portland, Ore. and Duarte, Calif.

  • 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

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 the 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 population.

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 Registry. 

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

Oregon 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 clinics 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, Twitter, YouTube or Instagram.