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Attitudes of Oregon psychiatrists toward physician-assisted suicide.

OBJECTIVE: After passage, in November 1994, of Oregon's ballot measure legalizing physician-assisted suicide for terminally ill persons, the authors surveyed psychiatrists in Oregon to determine their attitudes toward assisted suicide, the factors influencing these attitudes, and how they might both respond to and follow up a request by a primary care physician to evaluate a terminally ill patient desiring assisted suicide. METHOD: An anonymous questionnaire was sent to all 418 Oregon psychiatrists. RESULTS: Seventy-seven percent of psychiatrists (N = 321) returned the questionnaire. Two-thirds endorsed the view that a physician should be permitted, under some circumstances, to write a prescription for a medication whose sole purpose would be to allow a patient to end his or her life. One-third endorsed the view that this practice should never be permitted. Over half favored Oregon's assisted suicide initiative becoming law. Psychiatrists' position on legalization of assisted suicide influenced the likelihood that they would agree to evaluate patients requesting assisted suicide and how they would follow up an evaluation of a competent patient desiring assisted suicide. Only 6% of psychiatrists were very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide. CONCLUSIONS: Psychiatrists in Oregon are divided in their belief about the ethical permissibility of assisted suicide, and their moral beliefs influence how they might evaluate a patient requesting assisted suicide, should this practice be legalized. Psychiatrists' confidence in their ability to determine whether a psychiatric disorder such as depression was impairing the judgment of a patient requesting assisted suicide was low.

Attitude of Health Personnel↗

Attitudes and experiences of Oregon hospice nurses and social workers regarding assisted suicide.

BACKGROUND: When the Oregon Death with Dignity Act (ODDA) legalizing physician-assisted suicide was enacted into law in 1997, Oregon hospice clinicians were uncertain how involved they would be with patients who wanted this option. However, 86% of the 171 persons in Oregon who have died by lethal prescription were enrolled in hospice programmes. METHOD: A mailed questionnaire was sent to all hospice nurses and social workers in Oregon in 2001 (n=573) to assess their attitudes about legalized assisted suicide and interactions with patients concerning this issue. Responses from 306 nurses and 85 social workers are included in this report. FINDINGS: Almost two-thirds of respondents reported that at least one patient had discussed assisted suicide as a potential option in the past year. Social workers were generally more supportive of both the ODDA and of patients choosing assisted suicide compared to nurses. Twenty-two per cent of all respondents were not comfortable discussing assisted suicide with patients. Ninety-five per cent of both groups, however, favoured hospice policies that would allow a patient to choose assisted suicide while enrolled in hospice and allow hospice clinicians to continue to provide care. INTERPRETATIONS: Nurses and social workers in hospices and other settings can expect to encounter patient questions about physician-assisted suicide, whether legalized or not, and must be prepared to have these discussions. Most hospice professionals in Oregon do not believe that assisted suicide and hospice enrollment are mutually exclusive alternatives.

Attitude of Health Personnel↗

Opinions and reactions of physicians in New Jersey regarding the Oregon Death with Dignity Act.

Physician-assisted suicide (PAS) was legalized in Oregon in 1997. In the study reported here, the authors surveyed a sample of New Jersey physicians with regard to Oregon's Death with Dignity Act and to whether similar legislation should be enacted in New Jersey. A 49-item questionnaire was sent to 563 physicians in New Jersey who were licensed in the specialties of family practice, internal medicine, surgery, psychiatry, and obstetrics/gynecology. The questionnaire contained sections pertaining to demographics, physicians' attitudes regarding PAS, and physicians' opinions on Oregon's Death with Dignity Act. A brief summary of the legislation was included in the mailing, which participants were asked to read before completing the questionnaire. Of the 191 physicians who responded to the survey, 55% agreed with legislation that would legalize PAS, and 59% said that a law similar to that enacted in Oregon should exist in New Jersey. However, only 47% of respondents indicated that they believed PAS to be consistent with the role of a physician to relieve pain and suffering. Slightly more than half of respondents indicated that they would refuse to participate in PAS and were concerned about issues such as professional and personal liability and the potential for abuse. Physicians in New Jersey will require additional information, education, and discussion of the ethical and legal implications of PAS before a law similar to that in Oregon could be proposed or considered.

Aged↗

Oregon's guidelines for physician-assisted suicide: a legal and ethical analysis.

Oregon's Death with Dignity Act was first passed by a ballot initiative in 1994, but numerous judicial challenges delayed implementation of the Act. In November of 1997, following the United States Supreme Court decisions in Vacco v. Quill and Washington v. Glucksberg, which left the states' power to regulate physician-assisted suicide undisturbed, the Oregon voters upheld their law. Oregon remains the only state in the nation to authorize physician-assisted suicide. The Task Force to Improve the Care of Terminally Ill Oregonians published a Guidebook for health care providers on the Oregon Act, and the New England Journal of Medicine recently issued a special report on the first year's experience under the Act. This paper analyzes the legal context of the Oregon Death with Dignity Act, discusses the efficacy of the tenets in the Guidebook, and explores ethical issues underlying the guidelines, particularly those pertaining to the meaning of a patient's request for assisted suicide and processes supporting informed consent.

Adult↗

Setting health care priorities: Oregon's next steps.

Since the proposal was first broached in 1987, a storm of controversy has engulfed Oregon's plan to prioritize the health care services offered to its Medicaid recipients. After two years of debate, community consultation, and public opinion polls, the Oregon Health Services Commission was mandated in 1989 to study prioritization as part of a package of bills enacted as the Oregon Basic Health Services Act. In March 1990 the commission released a draft list of ranked health care services for public comment... As part of the ongoing debate, the Hastings Center and the Wesley Foundation sponsored a two-day meeting in January 1991 in Wichita, Kansas, to provide opportunity for thoughtful, in-depth, informal analysis of the OBHSA model for health care reform...a majority felt that OBHSA, in the framework of progress toward larger reform goals, is an experiment worth trying. Some felt that even if OBHSA doesn't attain its larger goals it should be tried since it will extend access and may lead to better health outcomes among the poor. But the general view was that OBHSA is a valuable experiment only to the extent that it leads to a statewide system of universal health insurance in Oregon without creating special burdens for the state's poor....

Biomedical Technology↗

The Oregon Health Plan: development and implementation of an innovative method of delivery of health care services to the medically indigent.

BACKGROUND: Health care for the medically indigent under the federal Medicaid system often provides care for only a fraction (ranging from 20% to 80%) of the poor who nominally qualify for care. Oregon has developed a unique system that replaces such a system with one that provides a comprehensive complement of medical care for all the poor but limits the care to conditions and procedures on a prioritized list. METHODS: The Health Services Commission, a group of physicians, nurses, and public representatives, developed a list of over 740 diagnoses-treatment pairs and, with considerable public input, prioritized them in order of importance. The principal values used to develop the list were the prevention of death and the cost of the disease and its treatment. In the final ordering of the diagnosis-treatment pairs, public health and prevention of morbidity was also considered. Cancer diagnoses, and indeed all diseases, were not singled out for special consideration in this process. The Oregon Health Plan was implemented in 1994 with funds to cover 606 of 743 listed diagnoses. Diagnoses involving cancer were nearly all covered within these 606 items. The principal exception was coverage for Curative Treatment for Cancer when the likelihood for success was less than 5%. RESULTS: The prioritized list has met its goal of comprehensive medical care for the indigent population. The number of medically uninsured Oregonians has fallen significantly, and there have been few complaints about the Plan. Cancer care has been delivered to Oregon Health Plan clients with very few complaints or appeals of decisions concerning coverage. Palliative care is provided under a number of covered lines, as are curative medical and surgical treatment. CONCLUSIONS: The Oregon Health Plan represents an alternative method for delivering medical care, including the full range of cancer care, to the indigent. As there are limited funds in all state systems, the citizens of Oregon have decided to provide care using a prioritized list to allow provision of medical care to the entire Medicaid population. Such a plan represents a viable alternative to the more common method of providing everything but only to a limited number of poor citizens.

Cancer Care Facilities↗

Development of a Bird Integrity Index: measuring avian response to disturbance in the Blue Mountains of Oregon, USA.

The Bird Integrity Index (BII) presented here uses bird assemblage information to assess human impacts to 28 stream reaches in the Blue Mountains of eastern Oregon. Eighty-one candidate metrics were extracted from bird survey data for testing. The metrics represented aspects of bird taxonomic richness, tolerance or intolerance to human disturbance, dietary preferences, foraging techniques, and nesting strategies that were expected to be positively or negatively affected by human activities in the region. To evaluate the responsiveness of each metric, it was plotted against an index of reach and watershed disturbance that included attributes of land use/land cover, road density, riparian cover, mining impacts, and percent area in clearcut and partial-cut logging. Nine of the 81 candidate bird metrics remained after eliminating unresponsive and highly correlated metrics. Individual metric scores ranged from 0 to 10, and BII scores varied between 0 and 100. BII scores varied from 78.6 for a minimally disturbed, reference stream reach to 30.4 for the most highly disturbed stream reach. The BII responded clearly to varying riparian conditions and to the cumulative effects of disturbances, such as logging, grazing, and mining, which are common in the mountains of eastern Oregon. This BII for eastern Oregon was compared to an earlier BII developed for the agricultural and urban disturbance regime of the Willamette Valley in western Oregon. The BII presented here was sensitive enough to distinguish differences in condition among stream riparian zones with disturbances that were not as obvious or irreversible as those in the agricultural/urban conditions of western Oregon.

Animals↗

Ten-year results of the Oregon program with 295 consecutive heart transplants in the Pacific Northwest.

BACKGROUND: The Oregon Cardiac Transplant Program provides a regional service. Since December 4, 1985, 284 patients, including 14 children, from Oregon, Washington, Idaho, Alaska, and Hawaii, underwent 295 orthotopic heart transplantation procedures at the Oregon Health Sciences University. Eleven patients underwent transplantations twice. METHODS: Detailed, up-to-date follow-up data were available on all patients. All patients have been followed up prospectively for transplant-related complications. RESULTS: The most common recipient diagnoses were coronary artery disease (50%) or idiopathic cardiomyopathy (33%). The mean age of the recipients was 48 +/- 15 years (range, 3 months to 68 years). Donor hearts were retrieved from a procurement area of a 1,500-mile radius that involved Oregon, Washington, Idaho, Nevada, Utah, California, and Canada. The mean donor age was 28 +/- 11 years and the donor heart ischemia time was 180 +/- 56 minutes. The median recipient waiting time was 75 days. Operative mortality was 6%. One-year, 5-year, and 10-year actuarial patient survival rates are 86 +/- 2%, 74 +/- 3%, and 59 +/- 5%, respectively. The majority of survivors are in very good functional status. CONCLUSIONS: Now, more than 10 years into its existence, the Oregon Heart Transplant Program has fulfilled its goal of providing a most effective treatment option for patients with end-stage heart disease in the region.

Adolescent↗

Investing in Oregon's expanded food and nutrition education program (EFNEP): documenting costs and benefits.

OBJECTIVES: To apply Virginia's cost-benefit analysis (CBA) model developed for a large Expanded Food and Nutrition Education Program (EFNEP) to Oregon's small EFNEP. To estimate a cost-benefit ratio for Oregon's EFNEP based on retrospective analysis of program costs and optimal nutrition behaviors (ONBs) in relation to potential health-related savings for diet-related chronic diseases/conditions. DESIGN: Standard components of a CBA. SUBJECTS/SETTINGS: 368 adult graduates of Oregon State University's Extension Service EFNEP during the 1999-2000 program year. INTERVENTION: Prior participation in the EFNEP with a mean of 10.4 lessons. MAIN OUTCOME MEASURES: Cost-benefit ratio and several sensitivity analyses. ANALYSIS: EFNEP program graduates practicing ONBs related to prevention/delay of diet-related chronic diseases/conditions were determined using SPSS (Base 10 computer program). Cost-benefit ratios were computed using Microsoft Excel. RESULTS: CBA determined a 1:3.63 cost-benefit ratio (in 1999 dollars). CONCLUSIONS AND IMPLICATIONS: Virginia's CBA model was useful in the retrospective evaluation of Oregon's small EFNEP. With Oregon's benefits exceeding costs, CBA provides evidence for resource allocation and justification for program continuation.

Adult↗

Oregon hospice nurses and social workers' assessment of physician progress in palliative care over the past 5 years.

BACKGROUND: The 1997 enactment of the Oregon Death with Dignity Act intensified interest in improving physician education and skills in caring for patients at the end of life. OBJECTIVE: To obtain hospice nurse and social workers' collateral ratings of efforts made by Oregon physicians to improve their palliative care skills over the previous 5 years. DESIGN: A descriptive survey of nurses and social workers from all 50 Oregon outpatient hospice agencies. MEASUREMENT AND RESULTS: Oregon hospice nurse (N=185) and social worker (N=52) respondents, who had worked in hospice for at least 5 years, rated changes they observed over the past 5 years in physicians' approach to caring for their hospice clients. Six characteristics, including willingness to refer patients to hospice, willingness to prescribe sufficient pain medications, knowledge about using pain medications in hospice patients, interest in caring for hospice patients, competence in caring for hospice patients, and fearfulness of prescribing sufficient opioid medications were evaluated. Positive changes were endorsed by the majority of respondents on all but the scale measuring fearfulness of prescribing opioid medications; on the latter, 47% of nurses rated doctors as less fearful, whereas 53% rated them as about the same or more fearful than they were 5 years earlier. CONCLUSIONS: Most respondents rated Oregon physicians as showing improvements in knowledge and willingness to refer and care for hospice patients.

Analgesics, Opioid↗

Equality, explicitness, severity, and rigidity: the Oregon plan evaluated from a Scandinavian perspective.

This article is an attempt to evaluate the Oregon plan from the perspective of a Scandinavian national health care system. The Nordic welfare states are marked by a strong emphasis on equality. As an example of an egalitarian system we present the Norwegian health care model in part one. In part two, the arguments in favor of a one tier system in Norway are presented and compared to Oregon's two tier system. Although we argue, in part three, that a comparison of the degree of explicitness in the prioritization process shows that Norway has much to learn from Oregon, we do believe that the Norwegian system has some attractive elements that may function as an important corrective. In part four we present the Norwegian Guidelines for priority-setting and discuss the weight assigned to the severity of disease criterion. It is argued that the exclusion of information about the severity of disease partly explains the counterintuitive ranking of treatment-condition pairs in Oregon's initial method based on the principle of health maximization. A normative analysis of the conflicting norms of efficiency and equality of results is called for. The final part of the paper is devoted to the problem of rigidity. Henry J. Aaron has argued that the Oregon system is insensitive to inter-individual variations within each diagnosis-treatment pair. This objection is a severe one, since the system might end up treating patients unfairly on the individual level. To overcome this problem, we suggest a selection rule that should be more capable of dealing with the problem of rigidity.

Community Participation↗

Oregon emergency physicians' experiences with, attitudes toward, and concerns about physician-assisted suicide.

OBJECTIVE: To determine emergency physicians' (EPs') attitudes toward physician-assisted suicide (PAS), factors associated with those attitudes, current experiences with attempted suicides in terminally ill persons, and concerns about the impact of legalizing PAS on emergency medicine practice. METHODS: A cross-sectional, anonymous mailed survey was taken of EPs in the state of Oregon. RESULTS: Of 356 eligible physicians, 248 (70%) returned the survey. Of the respondents, 69% indicated that PAS should be legal, 65% considered PAS consistent with the physician's role, and 19% believed that it is immoral. The respondents were concerned that patients might feel pressure if they perceived themselves to be either a care burden on others (82%) or a financial stress to others (69%). Only 37% indicated that the Oregon initiative has enough safeguards to protect vulnerable persons. Support for legalization was not associated with gender, age, or practice location. Respondents with no religious affiliation were most supportive of PAS (p < 0.001), and Catholic respondents were least suppportive (p = 0.03). A majority (58%) had treated at least 1 terminally ill patient after an apparent overdose. Most respondents (97%) indicated at least 1 circumstance for which they would sometimes be willing to let a terminally ill patient die without resuscitation after PAS if the Oregon initiative becomes law: if verified with an advance directive from the patient (81%), with documentation in writing from the physician (73%), after speaking to the primary physician (64%), if a competent patient verbally confirmed intent (60%), or if the family verbally confirmed intent (52%). CONCLUSIONS: Although the majority of Oregon EPs favor the concept of legalization of PAS, most have concerns that safeguards in the Oregon initiative are inadequate to protect vulnerable patients. These physicians would consider not resuscitating terminally ill patients who have attempted suicide under the law's provisions, only in the setting of documentation of the patient's intent.

Adult↗

The rationing of health care: should Oregon be transported to Australia?

The Oregon Plan is an ambitious attempt to address the widespread problem in the United States of a growing number of individuals who are without private health insurance and are not eligible for federal assistance programs. Its aim is to provide universal access for all Oregonians, without increasing total health care expenditure, by restricting the cover of some treatments. It has aroused interest in Australia and elsewhere. The appeal of the Oregon Plan lies in its explicit approach to rationing, in community participation in setting priorities, and the use of a cost-effectiveness framework. This paper describes the beginnings and the development of the Oregon Plan, and compares the actual development of the Plan with the rhetoric. There is a gap between the rhetoric of the Plan and its reality. The Oregon plan should be considered in the context of the United States health care system. We compare the American problems with those facing the Australian health care system and conclude that the answer to the question of whether Oregon should be transported to Australia is no. Nevertheless there are elements of the rhetoric of the Plan which could be applied in rationing health care in Australia.

Health Care Rationing↗

Characterization of the Oregon isolate of Neospora hughesi from a horse.

Neospora hughesi was isolated in cell cultures inoculated with homogenate of spinal cord from a horse in Oregon. Tachyzoites of this Oregon isolate of N. hughesi were maintained continuously by cell culture passage and tachyzoites were infective to immunosuppressed mice. Gamma interferon gene knockout (KO) mice injected with tachyzoites developed fatal myocarditis and numerous tachyzoites were seen in lesions. Gerbils (Meriones unguiculatus) inoculated with tachyzoites developed antibodies (> or = 1:500) as indicated by the Neospora caninum agglutination test but did not develop clinical signs, and Neospora organisms were not demonstrable in their tissues. Tissue cysts were not found in gerbils, nude mice, KO mice, immunosuppressed outbred Swiss Webster mice, or BALB/c mice injected with the Oregon isolate of N. hughesi. Ultrastructurally, tachyzoites of the Oregon isolate from the myocardium of infected KO mice and from cell culture were similar to N. caninum tachyzoites. Western blot analysis using NcSAG1 and NcSRS2 polyclonal and monoclonal antibodies and characterization of the internal transcribed spacer 1 sequences from the equine isolates and different isolates of N. caninum from dogs and cattle indicated that the Oregon isolate of N. hughesi is distinct from N. caninum isolates from cattle and dogs.

Animals↗

Racial misclassification of American Indians: its effect on injury rates in Oregon, 1989 through 1990.

OBJECTIVES: We assessed the extent to which injury rates among American Indians in Oregon are underestimated owing to misclassification of race in a surveillance system. METHODS: The Oregon Injury Registry, a population-based surveillance system, was linked with the Indian Health Service patient registration file from Oregon, and injury rates for American Indians were calculated before and after correcting for racial misclassification. RESULTS: In 1989 and 1990, 301 persons in the Oregon registry were coded as American Indian. An additional 89 injured persons who were coded as a race other than American Indian in the registry were listed as American Indian in the Indian Health Service records. The age-adjusted annual injury rate for health service-registered American Indians was 6.9/1000, 68% higher than the rate calculated before data linkage. American Indian ancestry, female sex, and residence in metropolitan counties were associated with a higher likelihood of concordant racial classification in both data sets. CONCLUSION: Injury rates among American Indians in an Oregon surveillance system are substantially underestimated owing to racial misclassification. Linkage of disease registries and vital records with Indian Health Service records in other states may improve health-related data regarding American Indians.

Adult↗

Rationing medical care: rhetoric and reality in the Oregon Health Plan.

The Oregon Health Plan (OHP) has been widely heralded as an important innovation in medical care policy and rationing. Oregon's pioneering method of prioritizing funding for health care through systematic and public ranking of medical services has drawn substantial international interest. This paper reviews the experience of the Oregon plan since it began operation in 1994. We argue that widespread misconceptions persist about the significance of the OHP. In particular, there is little evidence that the OHP has operated as a model of explicit rationing. In reality, Oregon has not rationed services, nor has its policy of cutting public coverage for services produced substantial savings. These findings have important implications regarding the desirability and feasibility of adopting a policy of removing items from the list of insured medicare services in Canada. Oregon's experience suggests that drawing the line on medicare coverage would be more difficult and less financially rewarding than advocates claim.

Health Care Rationing↗

Tobacco tax initiative--Oregon, 1996.

In 1995, tobacco use contributed to the deaths of 6274 persons in Oregon (1995 population: 3,132,000) as reported by physicians on death certificates; annual costs in Oregon for the direct and indirect consequences of tobacco use were approximately $1 billion (State Health Division, Oregon Department of Human Resources, unpublished data, 1997). In response to the health burden associated with tobacco use in Oregon, in late 1995 a statewide coalition of health-care and tobacco-use prevention interests began a petition-driven citizen initiative, "Measure 44", to increase the tax on each pack of cigarettes from .38 to .68 and the tax on noncigarette tobacco products from 35% to 65% of wholesale price beginning February 1, 1997. This report presents findings of surveys conducted before and after the measure was approved by voters; in both surveys, respondents indicated that support for such an initiative was increased by dedicating a portion of the new revenue to tobacco-use prevention and education and to expanded insurance coverage under the Oregon Health Plan (OHP) for medically underserved persons.

Humans↗

Evaluation of Malolactic Bacteria Isolated from Oregon Wines.

Oregon is a cool wine-producing region where grapes characteristically contain high concentrations of organic acids. To reduce the natural acidity and increase the microbiological stability and flavor complexity of the wine, malolactic fermentation is encouraged. In this study, strains of Leuconostoc oenos indigenous to Oregon wines were evaluated for their suitability to conduct malolactic fermentation in Oregon wines. Tests determined the malolactic activity of the Oregon isolates in comparison with commercial strains ML-34, PSU-1, MLT-kli, and ens 44-40 under various temperature and pH conditions. Sensitivities to sulfur dioxide, ethanol, and fumaric acid also were determined. Two Oregon strains, Er-1a and Ey-2d, were selected for commercial winemaking tests because they had greater malolactic activity under conditions of low pH (3.0) and low temperature (15 and 8 degrees C), respectively.

Journal Article↗