La Crosse, Wisconsin—The Best Place to Die in America

One place Katy Butler might have gone for help was La Crosse, a small city on the Mississippi River in Wisconsin. La Crosse is known for its steamboats, Wisconsin cheese, and its excellent end-of-life care. La Crosse is the home of the Gundersen health system, ranked in the top one percent of hospitals nationwide.⁴ An astounding 96 percent of all La Crosse residents who died last year had completed advance directives.⁵ That figure far exceeds the number of people who complete advance directives in the Bay Area and the rest of the country. Dr. Bud Hammes, a medical ethicist at

Gundersen, led the effort to improve end-of-life care in La Crosse. The key to success, says Hammes, was creating a supportive culture of person-centered care that honors a patient’s goals and values. “It isn’t just about training a few people to have these conversations with patients,” said Hammes, “It’s actually about changing the culture of the health care system and ultimately of the community.”

To change the culture at Gundersen, Hammes convinced hospital administrators in the late 1980s that end-of-life care needed to be given higher priority. An electronic medical record system was created to document patient preferences. That way, advance directives are easily accessible and can’t get lost.

End-of-life conversations and advance directives are now part of the hospital’s routine practice. Michael Sigmund is a long-time La Crosse resident and patient at Gundersen. He said, “It’s 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?’ ”

Others come to Gundersen to complete their advance directives because of peer pressure from friends and family. Karen (who did not want her last name used) sought out the assistance of Gundersen facilitator Janet Olmstead for help with her advance directive. Karen put off this visit for many years, but finally overcame her hesitancy after speaking with a friend. “I don’t want somebody else stuck with making decisions,” said Karen, “It’s a burden for them to make decisions that they don’t know what I want. So I just thought, ‘Now is the time.’ ”

Karen says she doesn’t want heroic measures or life-prolonging treatments if she’s no longer functional. Like Karen, many of Gundersen’s patients want medical treatments stopped if there’s little or no hope of recovery. Honoring patient preferences has resulted in fewer tests and expensive procedures. “We are very successful in outcomes in decreasing the costs at the end of life in comparison to lots of other systems,” said Gundersen’s CEO Dr. Scott Rathgaber, “I can tell you that’s millions of dollars that are left on the table because of our commitment to the patients.”

The Gundersen program was so successful that Hammes took it city-wide. In the early 1990s, Gundersen partnered with the other three local hospitals and formed a coalition called Respecting Choices.⁶ It brought churches, social service agencies, and nursing homes together and trained their staff to do community education and outreach. This concerted twenty-five year campaign has done much to raise public awareness around end-of-life planning and advance directives.

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