Tuesday, November 17, 2009

Why This Wisconsin City is the Best Place to Die.

A story from NPRs broadcast yesterday looks at La Crosse, Wisconsin, where, because of the local hospital, 96% of elderly community members have advance directives (living wills). The article shows the hospital's efforts have saved thousands of dollars per patient by not pursuing aggressive treatments that patients don't want, only those they desire.

The hospital database records patients' preferences and such information comes up any time the patient is in the hospital. Chaplains, doctors, nurses and others have been trained to update the patient's desires whenever they visit the hospital - which results in an ongoing conversation about the patient's end of life wishes not only at the hospital but among family members. From the story:

But it's expensive to spend time with patients filling out living wills. Medicare doesn't reimburse for the time the hospital's nurses, chaplains and social workers do this. Bud Hammes, the medical ethicist who started the program, called Respecting Choices, says it costs the hospital system millions of dollars a year. "We just build it into the overhead of the organization. We believe it's part of good patient care. We believe that our patients deserve to have an opportunity at least to have these conversations."

And that's how La Crosse unexpectedly got in the middle of the national debate over health care and the so-called "death panels."

A New Standard Of Care

There's a proposal — it's in the health bill passed by the House of Representatives — that would pay for the kind of periodic and continued end-of-life discussions with patients that are routine in La Crosse. Gundersen Lutheran is pushing for it.

Hammes says claims that government-run panels would pressure sick people to die are bizarre exaggerations — and that the experience of this Wisconsin city proves it. "These are conversations that we have with our patients. They're not done in a secret room," Hammes says. "These are open conversations involving family members, pastors, attorneys. It's part of our community fabric now, it's part of how we deliver care."

One result of the way that care is delivered: At Gundersen Lutheran, less is spent on patients in the last two years of life than any other place in the country


Further debunking the claim that end of life discussions lead to coercion of patients to die, the hospital shows that providing patients with choice reduces anxiety, over-treatment, and cost.

The Dartmouth Atlas of Health Care documents the vast difference in health care costs from one place in the country to another. At Gundersen Lutheran, the cost of care for someone in the last two years of life is about $18,000. The national average is close to $26,000. At one hospital in New York City, it's more than $75,000.

"When people see the low cost in La Crosse, there are assumptions about rationing care, about denying care, about limiting — that we limit care for our patients," says Hammes. But it's not that dying people in La Crosse are denied care, he says. It's that they've thought out their wishes in advance, so they get exactly the care they want. And often that means avoiding excessive and unwanted care.


Hammes says the point is to help people make informed choices. Decisions made on the spur of the moment, in crisis, can lead to costly and unwanted care. If a patient's wishes aren't clear, the default choice of doctors and family is often to provide high levels of care — even when it's something unhelpful.

But sometimes, getting a patient to think through choices can mean the patient decides he or she does want the most expensive care.

I have long claimed that rationing could be ameliorated by detailed conversations with elder and terminal patients about their options and choices. In a system that defaults to "every effort" care when most surveyed prefer to die at home or to not undergo excessive treatment, informing patients of their choices and letting them take control of their care choices is just good medicine - and more efficient. Glad to see La Crosse and Gunderson Lutheran taking the lead, standing up for patients' rights, and proving the point that great care does not necessarily equal over-testing, over-treating, and over-medicating.

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