Transitions in end-of-life care: the Oregon trail.

Hospitals can create an environment that supports patients, families, and healthcare professionals so that they are better able to recognize the best way to care for each patient during times of transition. This article highlights some of the supports intentionally put into place to assist patients, family, and staff through difficult transitions at Oregon Health & Science University. These supports include an expert inpatient and outpatient palliative care team to coach patients, families, and staff at the bedside; statewide efforts to raise the skill level of all healthcare professionals through education; and the Physician Orders for Life-Sustaining Treatment (POLST) program, which helps ensure that care decisions made in one setting are respected as the patient moves to another care setting.