 Our next speaker is Dr. Susan Toll. Susan attended Oregon Health and Science University for medical school, completed her internal medicine residency at UC San Diego where she was chief resident. Susan then completed the McLean Fellowship in 1988-89 after which she went on to found the Oregon Health and Science University Center's ethics program called Ethics in Health Care, which she has directed since 1989. Susan was the youngest person ever appointed as a professor at the Oregon Health and Sciences University. In 2014, Susan received the McLean Center Prize for her outstanding work in developing and nurturing the POST system, a system which has now been adopted by 44 legislatures in the United States and for improving end-of-life care throughout the country. Today, Dr. Susan Toll will talk on the following topic, transforming end-of-life care. It takes more than a POST form. Please join me in giving a warm welcome to Dr. Toll. The first thing is, who's having the conversation? We now have a form in our registry and some have forms and it's not in the registry, but we're able to look back and see who is signing POST forms. And we look to see who is signing POST forms for patients whose death certificates indicate that their primary consequences are cancer. How often do you think it's beyond POST? Very close. So we looked at over 6,000 POST forms and about half of patients with cancer have one. And it's 15%. Primary care is carrying much of the freight here. And we don't know, of course, how much oncologists may have talked to people. This follows, Gretchen's talk perfectly about what is being said and shared and what people are saying to one another. But the actual signature and the process of completing and submitting the forms is heavily done by primary care. Shift to the study that I was fortunate to have a very skilled and courageous colleague, Joan Tenno, partner with me in writing to look at the overall care of patients over a 13-year period of time near the end of life in Oregon, Washington, and the rest of the country. And to look at a question of the fact that most of the time people say they'd rather be at home than in an acute care hospital, an intensive care unit, that near the end of life, that is a very broad preference. It varies a little bit by certain kinds of demographics, but not a lot. And it's a majority in every group that's in a study. Most studies put the rate at about 90% of people saying, I would prefer something when, yes. There we go. So you see things that I don't see. That's very interesting. But this is dying at home. So we took 800,000 deeper service Medicare enrollment. And we looked at the year 2000, the year 2005, and the year 2013. We looked at Oregon, we looked at Washington, which demographically is a lot like us in many of ways. And they have had a full program since 2000. They vote in a similar way. There are many things about them that give us a close look. But yet quite a much lower rate of that at home. Home by our definition is not a skilled nursing facility not an inpatient hospice and not a hospital. So if you live in a assisted living van, you need a home. And it would be time to solve it. So you can see that Oregon is much higher and still rising for death at home, which most people say they want. We also went to Oregon. You end up hospitalized near the end of life. You are far more likely to go back home rather than to a hospital. Home hospice is used at much higher rates. It's part of the money that I own. Because there's so many to call. There's a plan. There's a backup. You can get it there you need. And ICU in the last 30 days of life is rising all across the country. And no more ICU beds to use them. But it's lower in Oregon and rising out a little bit lower. This is about a lot more than the post-order. This is about all kinds of interventions at all kinds of levels. We don't know which intervention has the most impact. It's the most important how the interventions relate to each other. But interventions have been made in individualized education for patients, as well as for health care professionals along with. We have had over 200 statewide and regional conferences to do some broad outreach. We've developed materials that kind of show in offices, booklets brochures, short videos. So that's at the individual level. We've at the state level created a statewide registry. Some things can be found very quickly. Next month, we will be popping out of the registry to every emergency department. The minute a patient registers and has a cold front, the form will actually go to the emergency department in the statewide system called M, which is the emergency department information state. So those are kind of government state level. At the more grassroots system level, we have very minimal hospice. They are super responsive. And in general, patients on Friday morning through the whole stroke and now our ultimate hospice, unless we've worked, we can usually get them rolled before the weekend. This means, of course, the hospice is not paid well over time and is not always the most economically advantageous to the hospice program. We have done a lot of things with the electronic registry. We have what's called biorectional. So on the patient header, it says, whole PS no. And automatically fed from the registry is not just what's in our epic record system, but anything in the registry pops up as yes. And there's a lot of pressure and work to figure out how the time of these conversations can be honored. A lot more work to be done there. Clearly local champions matter, efforts to make change, bring about change in your individual health systems. There is an ongoing need for quality assurance. Our biggest problem is a little pulse that's made a lot of us better and we're seeing folks who are treated as people who are too healthy. And there's some challenges and concerns. Welcome to Medicare. Some people are figuring it out on 165-year-olds as part of their process. These are your capital forms and trying to get advanced directives turned in. So there are some quality things that need constant monitoring. I am concerned about the public trust that clearly our economic systems are changing. It used to be in the service and what you did and what you made. Now obviously it's more of a route or the care of the patients that incentive has flipped. And to more of a pressure to encourage the conclusion of pulse harm that people were too healthy. The public trust is at risk and especially if we look at it to relate it to conflict of interest and policies that teachers who is funding in trying to have an incentive or encouragement to complete pulse forms and perhaps counting them as quality measure those kinds of things that we've been concerning. We have since been so concerned about the situation in Oregon which does not accept healthcare and the support for the whole program that we could actually put on for the national whole paradigm because then the cost is usually on this issue and I'm deeply concerned where it would take us with regard to the public trust. All of these things shared and some of the background materials are available on our website and there's lots more to add to that. It is such an honor to mention we will not have a conflict which might have happened to Dr. Welch and all our students. And Mark, thank you to everyone who's been a part of this meeting. Encourage, facilitate, and have special respect. Dr. Tull, thank you so much. I have to admit when you said you pulled out of the national pulse paradigm my jaw dropped and I felt a knot in my stomach. You are pulsed. Could you tell us more about what your differences are with it? Susan, that was phenomenal and I just marvel at how much of a force of nature you are. I mean, this is just extraordinary work that you've done. It's really impressive. I'm wondering if you could talk just a little bit about some special populations and pulsed forms, particularly given that there's some rules around hospice. So there's some people who I might imagine who would want a pulsed form but actually don't have access to hospice. One example is patients with end stage renal disease who would have to stop doing dialysis in order to receive hospice. So how does pulsed work for them? And does that allow them to get access to home care at the end of life instead of having to go to the hospital? Nephrologist, plan dialysis. But Jean Anderson just gave a talk. Should we be dialyping around, as to any grand round? So we're engaged. Yeah, great. Thank you again to everyone. Thank you to the plane. Thank you more. Susan, thank you. Thank you.