DISCUSSION

The initial 1994 voter approval and enactment of the ODDA in 1997 led to speculation that the option of PAS would erode efforts to encourage physicians to learn about and to improve palliative interventions for terminally ill patients (Drane, 1995; Foley, 1997; Sobel & Layton, 1997; Faber-Langendoen, 1998; Hendin et al., 1998). In 1999, Oregon physicians as a majority described themselves as having improved their knowledge about palliative care and the use of pain medications since passage of the act, and they endorsed feeling more confident about prescribing pain medications (Ganzini et al., 2001). These findings were especially important given that provision of comfort care interventions such as these has been significantly associated with patients changing their minds about assisted suicide (Ganzini et al., 2000). Physicians, however, may not be the best sole judges of their own progress, and their actual skill and knowledge in end-of-life care was not assessed. Hospice organizations provide support to approximately 37% of those who die in Oregon (Ann Jackson, Oregon Hospice Association, pers. commun.), and 83% of those who have chosen physician-assisted suicide have been enrolled in hospice. In some Oregon hospices, the hospice medical director cares for enrolled patients, but for the majority of hospice patients, their own primary care provider continues to care for them throughout the hospice course. The nurses and social workers of Oregon hospice organizations are in a unique position to independently evaluate the strides made by their physician colleagues over the past 5 years.

In this study, the majority of Oregon hospice workers reported their opinion that physicians had made positive strides towards improving their ability to care for hospice patients. Three quarters of respondents positively rated physician progress in learning about pain medications; the same self-appraisal was endorsed by 76% of the physician respondents on the earlier study. Hospice workers also rated physicians as showing gains in their willingness to refer and care for hospice patients, and viewed them as increasingly competent in caring for their hospice patients over the past 5 years. Similarly, only 3% of Oregon physicians reported that they had made fewer referrals to hospice in the span between 1994 and 1999; 30% reported they had increased the number of hospice referrals. In Oregon, the number of patients who died in hospice care increased from 22% in 1994 (the year the ODDA passed) to 37% in 2002.

Taken together, these views offer further support for the encouraging conclusion that palliative care in Oregon has improved in the span from 1997 to 2001 when our survey was conducted. Our data do not allow attribution of this positive change directly to the ODDA. Nationwide there have been extensive efforts to improve end-of-life care, and there are no data that allow us to compare progress made by physicians in other states. Since passage of the ODDA, however, many attempts have been made to improve palliative care. Educators at Oregon Health & Science University enhanced the medical school curriculum in end-of-life care beginning in 1995 (Lee & Tolle, 1996). Palliative care teams have been instituted at hospitals, conferences throughout the state have centered on end-of-life care, and efforts are underway to identify and remove barriers to hospice access (Tolle et al., 2000).

These findings were consistent across variables that theoretically might have influenced the opinions expressed. For example, hospice professionals endorsed improvements in physician willingness to refer to hospice uniformly across rural, medium city, and large urban settings, even though it may be more difficult to negotiate hospice referrals in sparsely populated regions and physicians in these areas may lack opportunities for education about end-of-life care. Support for or opposition to the ODDA did not have significant influence on nurses or social workers' overall positive appraisals of progress made by physicians over the last 5 years.

The prescribing of opioid pain medications poses a precarious balancing act for Oregon physicians. On the one hand, there have been extensive efforts to overcome physician resistance to treating pain in terminally ill patients. The Oregon Board of Medical Examiners (www.bme.state.or.us) has sanctioned a physician who consistently failed to adequately treat pain. On the other hand, physicians face questions from their state licensing board for opioid treatment that may result in a hastened death. Moreover, some may feel that the ODDA has resulted in increased scrutiny of their prescribing practices. The United States Department of Justice is actively pursuing efforts to overturn the ODDA and to punish physicians who prescribe lethal medications with the intent to hasten death. Physicians may anticipate being second-guessed as to their intentions. To some degree, this ambivalence is reflected in hospice professionals' rating of physician changes over the past 5 years regarding their fearfulness of prescribing sufficient opioid medications. While 47% of hospice workers rated physicians as “much less” to “a little less” fearful of prescribing opioids to sufficiently control pain, 27% ranked them as “about the same” as 5 years ago, and 26% ranked physicians as more fearful. Interestingly, physicians appear to remain fearful of consequences related to their prescribing practices, and yet they are providing better care despite their fears. A recent rating of end-of-life care in all 50 states by Last Acts (2002) advocates for more explicit state guidelines to address undertreatment of pain. In Oregon, there is currently no statewide policy on pain management. Given that adequate palliative care presents a critical alternative to physician-assisted suicide, these results suggest that physicians may continue to need clearly delineated guidelines and legal safeguards that prioritize pain management in order to prescribe for pain control with confidence.

There are several limitations to this study. We did not precede this survey with qualitative studies. As such, we may not have included items of importance that would have emerged in qualitative interviews. Not all hospice workers responded to this survey, and not all who responded completed every question. These data represent hospice workers' impressions, and the precision and validity of these impressions cannot be verified. As previously noted, across the United States similar efforts are being made to improve physician abilities to care for patients at the end of life. Because we did not survey hospice professionals in states other than Oregon, we cannot determine whether our findings are specific to Oregon or representative of secular changes across the nation.