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Case Study: Advance Care Conversations

Jim Molpus, for HealthLeaders Media, May 17, 2013

La Crosse now boasts rates among the nation's highest for advance care planning. As Atul Gawande, MD, wrote in his New Yorker piece "Letting Go," residents in La Crosse "have unusually low end-of-life hospital costs. During their last six months, according to Medicare data, they spend half as many days in the hospital as the national average, and there's no sign that doctors or patients are halting care prematurely. Despite average rates of obesity and smoking, their life expectancy outpaces the national mean by a year." An article in the Journal of the American Geriatric Society also found that:

  • 95% of severely or terminally ill patients in La Crosse have an advance care plan, compared to the national average of 50%
  •  98% of physicians are aware of the advance care plan, compared to a national average of 35%
  • 98% of the time there is consistency between the known care plan and the treatment provided, compared to a national average of 50%

Having a conversation with patients and their families about end-of-life care wishes needs to happen at the appropriate time, with a member of the care team who is appropriate for the need, and with someone trained in the nuances of difficult conversations. The current norm for advance care planning is much less structured and much less effective, says Bernard Hammes, PhD, director of medical humanities and Respecting Choices® for Gundersen Health System.

"The standard approach in the past was to tell patients about advance directives, hand them a document or maybe a brochure, and then tell them that they need to fill it out," Hammes says. "That kind of simplistic approach clearly has not worked. The evidence is pretty overwhelming that it's outright failed to do much of anything."

A flaw in many medical communities is the idea that only physicians can have advance care conversations with the patient and their family. "Medical leaders have to get out of the mind-set that the docs are going to spend hours and hours a day having these conversations," Thompson says. "Our job is to lead on this, not to have all the conversations. We can encourage it. We can make sure the system is set up. We can review the occasional confusing case. You can answer the patient's questions."

Hammes adds that telling physicians they should do more is rarely an effective engagement strategy anyway.

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