Assessing policies for end-of-life care in Washington state hospitals

Beacon, June 22nd, 2026

No one likes to think about their own death, but no one is exempt from it either. The quality of care that one receives is closely related to their ability to access advanced care planning services and understand their care options. In 2014, the Bree Collaborative aimed to help improve the quality of care that individuals receive at the end of their lives by providing guidelines clarifying the who, what, where, when and how of end-of-life planning that should occur in the health care ecosystem.

In 2026, we were able to leverage public facing information on end-of-life care policies at all hospitals across Washington state to determine how aligned they are with our recommendations. So, what was it that we actually recommended?

• that they educate providers on and encourage them to offer information and support for advanced care planning
• that they ask patients about whether or not they already have advance care planning documents and assist them with created them when they did not
• that they provide information and referrals for palliative care and hospice and work with community organizations to establish referral pathways
• that they honor a patients wishes and advance directives as much as possible
• that they have a process in place to review advanced directive and PLOSTs and to ensure that they are documented, including quality improvement and standardization of processes

The majority of hospitals, 52.7%, had policies that were completely aligned with Bree recommendations. We used the DOH’s checklist (EOLS checklist) to determine whether hospital policies were aligned with the Bree report. We found that the range of positive responses to EOLS items that were considered well aligned with Bree recommendations was 82.1% to 96.4% among Bree member hospitals and 52.3% to 80.0% among non-Bree member hospitals, indicating a high prevalence of Bree aligned policies implemented in Washington State hospitals. Although Bree member hospitals had consistently higher uptake of all EOLS checklist items, no item had 100% up-take at all hospitals.

In terms of offering advance care planning information, 68.6% of urban and 71.1% or rural hospitals “offers information & support for advance care planning including written information on the patient’s right to make decisions concerning medical care, the right to accept or refuse medical or surgical treatment, the right to formulate advance directives, & the hospital’s policies respecting the implementation of such rights”. Just 66.7% of urban and 62.2% of rural hospitals provided education on end-of-life care, and among the Bree members it was 85.7% compared to 69.2% among non-Bree members.

So, what does this mean? Overall this indicates that there may still be gaps in best-practices for end-of-life care, especially around planning and educational services. There are more, smaller hospitals in rural areas with a larger variation in uptake, meaning that there may still be places in rural Washington where end-of-life care planning is much more difficult to access or where access happens differently than in urban areas.. Once a patient has advanced care planning in place, our evaluation found that most hospital policies supported processes where patient wishes could be honored.

What’s missing and what’s next: We were not able to measure changes to policies over time or the impacts of the policies on patient care processes and outcomes. However, other evaluations on this same topic will aim to cover gaps in our understanding of alignment with our report more broadly. We are in the process of planning an evaluation of advanced care planning services that were provided between 2014 and 2024, using the all-payor claims database. Triangulation of this data against hospital policies will provide a clearer picture of the trends in advanced care planning services delivery.

Read our summary here: https://www.qualityhealth.org/bree/wp-content/uploads/sites/8/2023/06/Case-study-onepager-EOL_hospitals-1.pdf

Read our full report here: : https://www.qualityhealth.org/bree/wp-content/uploads/sites/8/2026/04/EOL_Hospital_final-report.pdf