Program enables patients to make informed decisions
Various stages of health require different planning
An innovative program that encourages physicians and other providers to facilitate the tough conversation about care at the end of life has resulted in 95% of the senior citizens in La Crosse, WI, having advance care directives that guide their care. Because most of those directives are Physician Orders for Life-Sustaining Treatment (POLST) forms, the wishes of the patient are carried out with no questions because they are physician orders, not just a legal document.
More important than the fact that the documents are completed and signed by seniors is the fact that people are discussing their health care wishes with providers and family members, says Bernard "Bud" Hammes, PhD, ethics consultant, director of medical humanities, and director of Respecting Choices, Gundersen Lutheran Medical Foundation, La Crosse, WI.
"When the health care providers of this community came together to create the Respecting Choices program to promote the importance of advance care planning, we focused on the process, not just the documents," Hammes says.
Although completion of living wills, health care power of attorney, and other types of advance directive documents was the ultimate result of the community effort, the focus was on facilitating conversations that provided information and options to people and their families. "We wanted to help patients and their families understand all of the issues and talk about decisions they were making," Hammes says.
A key strategic decision made by the task force comprised of leaders from the two health systems in the city was that no program would work if only physicians were involved, says Hammes. Physicians are a key component, but they are trained to diagnose and treat patients, he says. Many of them are not comfortable having discussions about end-of-life care that means no more curative treatment, he explains. "We created the new role of advance care planning facilitator throughout the community," Hammes says. "Facilitators undergo a training program that enables them to work with physicians to guide patients and their families through their decisions."
Advance care planning facilitators don't have to be clinicians, Hammes points out. "We trained social workers and chaplains in addition to nurses," he explains. Initially the 16-hour training program was offered four times per year, but it is now offered twice each year because there are fewer people that need training. "We train people from the health systems for free because the two organizations are underwriting the costs of the program, and we charge $100 per person for people from nursing homes or organizations outside the health systems," Hammes says.
Facilitators lead with no bias
The training focuses on how to facilitate a conversation about a patient's health status and options for future treatment without imposing the facilitator's bias on the conversation, says Hammes.
"We are always asked what we would do in certain situations when we are talking about difficult decisions that must be made, and this gives us the opportunity to have undue influence," he says. "After undergoing training, it becomes easier to explain that everyone has different values and goals, so everyone's decisions, including my own, may not be the right decisions for someone else."
The facilitator leads the patient through a discussion of personal values and goals and then discusses options that the patient can consider.
Although POLST is the document used in La Crosse since 1997, it is not used for all patients in the community, points out Hammes. "Timing is critical to having a successful discussion about advance care planning," he says. "Advance care planning happens in stages throughout a patient's life."
A basic plan that is comprised of designation of a power of attorney for health care is appropriate for younger, healthier patients, Hammes says. A more detailed, disease-specific plan is needed for a patient with a condition that means more risk of health care crises, such as advanced chronic heart failure. The final stage of planning is development of the POLST for patients who are at the stage where decisions regarding life support and extraordinary measures are realistic, he says.
"You have to time conversations to meet the needs of the individual, because no one can realistically discuss end-of-life decisions when they are young and healthy, so you address what is most important to them at the time," recommends Hammes. Although most patients completing advance directives are referred to a facilitator by a physician, home health representative, or nursing home staff member, there are some members of the community who choose to complete the documents with their attorneys. "We have worked with the local bar association to ensure that the same documents are used and that access to the documents is available through our database," he says. Attorneys also have access to facilitators if their clients want to consult them, he adds.
Hammes and other members of the Respecting Choices program are helping other communities set up similar programs. "We do have an advantage in our community because there are only two health systems and physicians are closely aligned with one or the other system," he says. "This made collaboration easier, but it doesn't mean that our model is the only one that will work."
An eight-hospital system in Illinois is taking the Respecting Choice approach as a standard of care within its system, a single-hospital city in another state is adopting the program, and the medical societies in Minneapolis and St. Paul in Minnesota are heading up the effort to become the first major metropolitan area to adopt the approach, he says. "The pilot program in Minneapolis and St. Paul is beginning, but two of the five health systems involved have been using some form of the program, so some participants have a head start on implementation," he says.
Need More Information?
For more information about Respecting Choices, go to www.respectingchoices.org. The web site contains information about consultations, training courses, printed materials, and research.
An innovative program that encourages physicians and other providers to facilitate the tough conversation about care at the end of life has resulted in 95% of the senior citizens in La Crosse, WI, having advance care directives that guide their care.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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