By Guy Bolton
Milwaukee Journal Sentinel
September 20, 2012
The Wisconsin Medical Society is launching a statewide initiative to make advance care planning – including the sensitive and often difficult conversations about end-of-life care – a standard part of patient care.
The initiative – Honoring Choices Wisconsin – is modeled after a communitywide initiative in La Crosse that has drawn national attention as well as a similar initiative by the Twin Cities Medical Society in Minnesota.
The goal is for the state’s health systems eventually to have people on staff trained to help patients understand and document the care they would want if they could not make decisions themselves.
“We know the tragedy of not having these conversations,” said Tim Bartholow, chief medical officer of the Wisconsin Medical Society.
The initiative will begin with a pilot project involving five health systems, including ProHealth Care, as well as the William S. Middleton Memorial Veterans Hospital in Madison and other organizations.
Respecting Choices, an outgrowth of the initiative in La Crosse, will provide the training for the participating health systems and organizations.
The nonprofit organization, part of Gundersen Lutheran Medical Foundation, had the same role in the Twin Cities Medical Society’s initiative and has worked with health systems and communities throughout the country.
“Some of the best work in the world is being done in La Crosse,” said John Maycroft, policy analyst at the Wisconsin Medical Society.
Respecting Choices will train nurses, social workers, chaplains and others who will help people with advance care planning.
The Wisconsin Medical Society hopes the sessions will lead to more people completing advance directives – written instructions on what care should be provided if they cannot make decisions on their own.
The participants in the initiative will use a standard form developed in La Crosse.
Other goals include increasing physicians’ understanding of advance care planning, hospice and palliative care, and improving end-of-life care.
Let wishes be known
The initiative could result in fewer patients dying in intensive care units and increased use of hospice care, although Maycroft stressed that this depends on patients’ wishes.
“This is not ever about pushing one particular decision over another,” he said. “We know that most people want less medical care at the end of life. However, some people want more.”
The idea is simply for patients to receive the care they want and for their wishes to be known, potentially sparing family members from agonizing decisions.
Advances in medical technology have enabled doctors to keep patients alive, said Bartholow, a family practice physician. But that is not always the same as providing better care.
“Medicine as a whole has been a little slow to the game on this,” he said.
The Wisconsin Medical Society, which has about 12,500 of the state’s doctors as members, has been working on the initiative for more than a year. It estimates the pilot project will cost $250,000 the first year.
Training will begin this month and the pilot project is scheduled to begin in March 2013.
The Wisconsin Medical Society also plans an ambitious community outreach program similar to one launched by the Twin Cities Medical Society.
Many take part
Last year, 14,000 advanced care planning sessions were held in Minnesota and almost 16,000 advance directives were recorded in patients’ electronic health records, said Sue Schettle, chief executive officer of the Twin Cities Medical Society.
The state now has more than 800 people trained as “facilitators” to help patients with advance care planning.
“It was the Twin City model that really showed how this could be done on a large scale,” Maycroft said.
ProHealth is the only health care system in the Milwaukee area participating in the pilot project, although Columbia St. Mary’s, which already has put an emphasis on advance care planning, may have an advisory role in the initiative.
Community Care, which oversees programs for people who are disabled and for the frail elderly, also is participating in the pilot project. Froedtert Health tentatively plans to participate in the next phase of the pilot project.
“Morally and ethically, it is the right thing to do,” said Patricia Starr, palliative care coordinator for ProHealth.
Nurses, doctors and other health care workers have seen what can happen when people have not done advance care planning, she said.
“That is something you don’t forget because it is very, very distressing for families,” said Starr, a registered nurse. “It causes a lot of discord.”
The Business Health Care Group, an employer coalition in southeastern Wisconsin, plans to support the initiative, said Dianne Kiehl, its executive director.
“There is nothing bad that comes out of it,” Kiehl said.
The health systems and organizations participating in the initiative will offer the program in at least one clinic, department or other site.
The project will track the number of patients offered help with advance care planning, the number of counseling sessions or “conversations” held with patients, and the number of new advance directives entered into patients’ medical records.
The participants also must agree to share what they learn, take part in monthly meetings, and to track and report their results.
The long-term goal is for the project to become a statewide initiative.
Honoring Choices Wisconsin will focus initially on just the first stage of advance care planning.
“What we’ve learned in La Crosse is end-of-life planning is a complex process and best done in stages,” said Bernard “Bud” Hammes, director of Respecting Choices.
“This is really a series of conversations,” he added. “And the conversations are needed over time because, as people age and as they develop serious illnesses over time, they need to rethink what is important.”
How to join
People and organizations interested in participating in the project can contact John Maycroft, policy analyst for the Wisconsin Medical Society, at firstname.lastname@example.org.