Part 3—What Can Be Done to Improve
La Crosse—The Best Place to Die in America
One place Katy Butler might have sought help for her father was in La Crosse in Wisconsin. La Crosse is a small city with a population of 50,000 on the Mississippi River. La Crosse is known for its excellent end-of-life care and is home to Gundersen Health System, ranked in the top one percent of all hospitals nationwide.
Long-time La Crosse resident Michael Sigmund says that planning for the end of life is standard procedure in La Crosse. He said, “Before you go see the doctor, it’s usually the nurse who asks the question when you first walk in the door. ‘How are you doing? You have any pains today? Do you have an advance directive?’ ”
An astounding 96 percent of all La Crosse residents who died had completed advance directives. That figure far exceeds the number of people who complete advance directives in the rest of the country. How did La Crosse achieve these high numbers? It was part of a forty-year campaign led by Dr. Bud Hammes, a bioethicist with Gundersen. Finding out what the patient wants is the starting point. The problem, said Hammes, was no one was asking this question. “I kept asking myself ‘Why isn’t anyone talking with the patient about their preferences, about their goals and values so that we might be better prepared for this event?’ ” said Hammes, “So I just asked the question ‘Couldn’t we change this? Couldn’t we make this better for everyone?’ ”
In the mid 80s, Hammes tried educating Gundersen’s younger doctors on having end-of-life conversations with their patients, but his efforts went nowhere at first. Although the doctors all agreed it was a good idea, they strictly followed the medical system’s protocol—a hospital outline that did not include end-of-life discussions. “So the light bulb went off,” said Hammes, “I realized that if I was going to have an impact, I actually had to change that outline.”
Change Comes to Gundersen Health System
The new outline drafted by Hammes required doctors to summarize their plans for future end-of-life care that includes patients’ goals and preferences. This was the first step that led to other profound changes in the medical culture at Gundersen. Medical staff learned to converse with dying patients. All patients were routinely informed about advance directives and their documents automatically became part of Gundersen’s electronic medical records. Facilitators were hired and trained to help patients with their end-of-life planning. “A lot of work at Gundersen and its success has been about this combination of actually redesigning the system and then training people to work in it,” said Hammes, “And the system that we want is a system in which knowing and honoring each and every patient’s values and preferences is the expected and routine of care.”
All new physicians at Gundersen now receive training in advance care planning. Dr. Greg Thompson is Gundersen’s director of medical education. He says over the years, the medical culture at Gundersen has shifted to a “patient-centered” model of care. The patient is in the driver’s seat, making informed choices and supported by a team of medical professionals, religious and social workers, and family. Any member of the team can review the patient’s advance directive to make sure his or her wishes are being followed. Thompson describes the safeguards in place to ensure that medical staff is honoring patient preferences. “If we have a situation where we find that a provider did not follow the directives in the advance care document, it goes to peer review to determine why it was not followed and if it was not followed, then there is follow-up with the physician to determine why not and to correct that action,” said Thompson.
Over the years, Gundersen has achieved better outcomes for dying patients and their families. Patients spend fewer days in the hospital compared to other medical centers. Medicare costs at Gundersen are significantly lower because many patients decline expensive, life-prolonging treatments and procedures. Thanks to aggressive community outreach efforts, the Gundersen model has spread to other hospitals in La Crosse and is being replicated nationally and internationally.