here for PDF format
here for participants' responses to this interview.
(Bud) Hammes, Gunderson Lutheran Medical Center
Civic Caucus, 8301
Creekside Circle #920, Bloomington, MN 55437
July 15, 2011
Verne Johnson (chair), Marianne Curry, Paul Gilje, Sallie Kemper, Dan
Loritz, Tim McDonald (phone), Wayne Popham (phone), Fred Zimmerman
Summary of meeting:
Bud Hammes, medical ethicist at Gundersen Lutheran Medical Center in La
Crosse, Wisconsin, discusses a program he started to encourage individuals
to make decisions about their future care before they become ill. He
describes the motivations for the effort and its impact: less stress on
families, greater peace in the final years of life, and substantial
savings in forgone cost of care. He discusses the politics and pragmatics
of starting and running the program.
Welcome and introductions
Hammes received his Ph.D. in philosophy from the University of Notre Dame.
He has taught at the University of Gonzaga in Spokane, Washington, and at
the University of Wisconsin-La Crosse.
1984, he has served as the Director of Medical Humanities and as Director
of the Respecting Choices Program for Gundersen Lutheran Medical
Foundation and Gundersen Lutheran Medical Center in La Crosse, Wisconsin.
In this position he provides educational programs for medical students,
nursing students and physician assistant students. He also provides
in-service training and workshops for the medical staff, nursing staff,
social workers, and the pastoral care department. He chairs both the
Institutional Review Board and the Ethics Committee.
are two major health systems in the La Crosse area, Hammes pointed out:
Gundersen Lutheran and Franciscan Healthcare, which is part of the Mayo
Clinic Health System. They are both integrated systems in that they
contain all health care services under one administrative staff-from
outpatient care to tertiary care in the hospital. So the two La Crosse
health systems compete with each other, yet they also cooperate when it
comes to doing something beneficial for the entire community. One such
opportunity to cooperate has centered on the movement to improve advance
care planning which has an impact on care at the end of life.
It is not right to make life or death decisions without knowing one's
outlined his interest in advanced care planning as it developed over the
course of his career.
started here at Gundersen in 1984," Hammes said, "and my initial role was
one educating young doctors. In that work I was closely involved in
observing the doctors taking care of patients, particularly in the
hospital. I was able to observe the process of care and the kinds of
ethical questions that physicians face in the hospital setting."
doing ethics consultations for the physicians and started to see some
troubling patterns. "We'd have patients in the hospital, many of whom had
been in before, who were so ill that they were unable to make decisions
about their own care."
the physicians coming upon situations where they were not sure whether a
patient would live if physicians intervened. "And it wasn't always clear
if patients would be 'in a good place' if we did intervene and kept them
alive. I had to consult with families about the ethics of the medical
decisions they faced. All too often the family didn't know what the
patient would want-and I was stuck over and over again in this same
situation with families facing the same difficult decisions.
were making potentially a life-or-death decision for someone when we had
no notion of what they'd want us to do under the particular circumstances
of their present condition."
A new approach to a common problem is developed.
wasn't an occasional occurrence, Hammes added, but rather a highly common
problem-one he found to exist around the world.
to our ethics committee and said that this not only appears to be a
widespread problem, but it is also preventable." He received support from
the ethics committee to start a trial program addressing the issue.
working with patients that were in end-stage kidney failure and on
my experience that even when people filled out documents specifying
guidelines for care, the mere completion of the documents did not
necessarily help. Just because you had filled out the forms didn't mean
that you had discussed your preferences with your family or that you had
made an informed decision that would coincide with the family's values and
wanted to have a discussion with patients and families to assure that they
understood what a patient's future might look like if possible
complications occurred following treatment.
staff at the hospital had various concerns: Who would direct these
conversations, who would participate, when would you do it, what issues
would you talk about, and what would be recorded so that decisions or
preferences would be documented?
It is a fallacy that more care extends life.
in the midst of drafting a book on end-of-life health care in
collaboration with the Center for Health Care Transformation, which was
started by Newt Gingrich. One common fallacy in this area is that more
care extends life. With a fuller understanding of the range of patient
choices better outcomes can result. Hospice care and palliative treatment
rather than continued acute-care, can, in fact, help people live longer
and with a significantly better quality of life."
People are willing and interested to discuss end of life care.
result of their trial project Gundersen Lutheran found that people were
quite willing to talk about future health care decisions including
end-of-life care. With their initial kidney failure population some
patients that began to have complications determined that if there was not
a reasonable likelihood of getting better, they did not want to continue
a rather high degree of skepticism we showed that could happen."
early 1990's the presidents of Gundersen and Franciscan began meeting
regularly to see how they could collaborate on the health of the
community. In 1991, the executives of all the major health organizations
decided to take the pilot program with renal failure patients and begin
offering it to all of the La Crosse community. Hammes was appointed the
chairman of the community task force and led the initiative that has since
become Respecting Choices.
Patient and family satisfaction increases with Respecting Choices.
task was to develop a process that would help patients effectively plan
for end-of-life care. The success of this kind of planning was
demonstrated in one of the most exhaustive studies on the topic published
last year in the British Medical Journal. What this study showed is the
people doing end-of-life planning in advance of critical illness are far
more satisfied with their care than those that don't. It makes people feel
as if they're part of the medical care team and that they're really
listened to. It starts to make patient care much more patient-centered."
positive outcome of advance care planning affects the family, Hammes said.
As the end of life approaches and as families deal with the difficult
questions that often arise, those families that have worked out a plan
ahead of time fare much better after the death of their loved one. The
study showed that there was a lower incidence of stress and depression
among those that did advance planning.
findings didn't strike me as surprising," Hammes said, "because that is
exactly the goal I had when I first got involved in this effort."
Respecting Choices saves money.
the most well-known outcomes of this study I know you are particularly
interested in," Hammes said. Most patients, when doing the planning,
identify areas where they would like to limit care. Usually this means
they prefer not to return to the hospital for acute care when that
additional care will either increase their suffering or have no positive
effect on their condition. Under these conditions, they would rather
remain in their home.
of the way heath care operates today, and with many once-fatal illnesses
no longer untreatable as in the past, most of us will die of longer-term
chronic illness," Hammes said. "And most of us will want to be able to
say, 'the next treatment is not worth it.' Many are choosing to do just
lets the care providers know when to stop-and lets the patient direct when
the care should stop. At present Hammes said health care professionals
often don't know when that point is, so patients are put through misery
that they may not have wanted and spend money they may not have to spend.
improves quality of care, quality of life, and overall cost, and benefits
the family in lessening the stress of an already difficult emotional
time," Hammes said.
program is now part of a pilot Medicare project for treating people in the
final two years of life. This pilot provides a nurse care coordinator who
can hasten access to staff to help facilitate end-of-life decision-making.
Advocates believe the program has the potential to save thousands of
dollars per year on individual health care costs. It saves this money NOT
by denying care to patients, but rather by allowing patients to make
informed decisions about their own care and treatment.
The current health care system does not offer incentives for this kind of
your incentive to run this program, a participant asked-doesn't it just
decrease the volume of your services and hence your income?
good question, Hammes observed-and a common one. He recalled the speeches
he makes to medical groups. Physicians always seem to respond well to the
tenets of the program. Yet, "At some point someone from the financial side
will say, 'Let me get this straight: you want us to train people, have
professionals spend time that doesn't get reimbursed, and decrease our
volume? Where's the business plan in this?'"
reaction is a bit tongue-in-cheek, he said, because many of these patients
are on Medicare, which is a capitated funding source and many are
high-utilization patients for whom you will not be fully reimbursed. So
with those patients there is indeed an economic incentive to avoid
expensive, unnecessary or unwanted services whenever it is also in the
patients' best interest to do so.
A similar program in Minnesota is underway.
Following a meeting he had with Minnesota care providers, Hammes said he
and his colleagues have been working with Twin Cities Medical Society in
Minnesota to bring a similar end-of-life planning program into our state.
He has been working closely with that group's Honoring Choices Minnesota
a metro area effort to promote end-of-life discussions and help health
care organizations facilitate in-house advance planning for end-of-life
care. The Citizens League is a partner in Honoring Choices Minnesota.
The program needs to ensure that physicians follow patients' wishes.
observed that it had been her experience that if a doctor disagrees with a
patient's health care directive he or she does not always adhere to them.
There appears to be a fundamental dichotomy between the culture of
physicians focused, sometimes obsessively, on saving lives and a more
humane approach allowing someone to choose to move gracefully from life to
plans necessarily matter a lot to everyone involved," Hammes emphasized.
The Gundersen program has a mechanism that requires any doctor who might
disagree with a patient's choice to have a consult with the ethics
committee. "They go to that committee before altering the plan for care.
We got a couple of these ethics consults each month at the beginning. Now
it's uncommon for physicians to override a patient's clear preference."
Crosse hospitals have peer review as well, as most hospitals do, and if
there is a death the committee looks to the directives of the patient and
determines whether they were followed. If they see that the wishes of the
patients were not followed, then the physician must be held accountable.
really come to the point that this respect for patients' end-of-life
decisions is an integral part of our organization's shared values."
Using non-physicians is key to facilitating the discussions.
participant asked: Does the system provide enough information to the
patients about risks and aftereffects? Contingencies seem often not to be
agree," Hammes replied, "and that's one of the reasons why in the
Respecting Choices approach we use non-physicians to facilitate the
discussions. A doctor once said that 'we haven't been trained in
this-we've only been trained to say 'if you don't do this, you're going to
die.'" This approach of talking about other potential outcomes is not
always compatible with physician training, which is so very focused on
extending life. Physicians often also don't have the 60-90 minutes to have
these complicated conversations. Training non-physicians who work
closely with the patient's physicians is a great solution because the
patient gets the assistance he or she needs to make the decisions,
including access to the physician when specific medical issues arise.
Begin the politics locally for end-of-life planning.
asked Hammes how he is engaging the politics of end-of-life
planning-particularly in light of the debates that led up to changes to
the federal health care law and all the talk of "death panels".
has definitely become a third rail for politicians, a topic that is in
many cases 'untouchable'," Hammes replied. "In recent years I have had
many politicians say they support it but don't want to publicly endorse
it. I believe that on a local level these issues can be discussed more
openly because of the trust relationships that exist among people within a
community. Recently Honoring Choices Minnesota held a meeting at an
Evangelical congregation, and the pastors attending supported the program.
So there appears to be widespread interest across ideological lines. But
the community conversation must begin with trust and keep focused on how
we can improve our health system to take better care of the sickest
close, Hammes said that to implement this kind of program it is important
to start in the local community. "During the uproar of death panels, a
bi-partisan group of locals announced that they were having a 'death panel
party'-they realized that they had not laid out their end-of-life plans,
so came to the party dressed as their favorite historic figures and
together straightened out all their health care directives and
powers-of-attorney. It helps to look on this as an opportunity to do
something positive. It is not about rationing care; it is about honoring
really need to change our language in this business. We need to talk about
the quality of living even in the last days of our life. That would help
people cope so much more effectively with this life-to-death cycle that we
all are part of."
to Hammes for a good overview of this important issue.