here for PDF format
here for participants' responses to this interview.
Kent Wilson, Medical Director, Honoring Choices Minnesota
8301 Creekside Circle #920, Bloomington, MN 55437
August 5, 2011
Verne Johnson (chair), David Broden, Janis Clay (phone), Marianne Curry,
Paul Gilje, Sallie Kemper, Tim McDonald, Wayne Popham (phone)
Summary of meeting:
The director of Honoring Choices Minnesota describes the development of
a program, led by the Twin Cities Medical Society and providers, to help
individuals decide and document their medical care and end of life
preferences in case they are unable to participate in treatment decisions.
He describes the inspiration for the program, the model in Wisconsin that
they followed, and the progress already underway in Minnesota.
Implications for cost savings and patient satisfaction are discussed, as
well as the program's prospects for implementation.
Welcome and introductions
the July 15th Civic Caucus interview with Bud Hammes, director
of Respecting Choices at Gundersen Lutheran in La Crosse, Wisconsin,
Hammes cited a similar effort underway in the Twin Cities. Kent Wilson,
MD, today's speaker, directs that project. See a report of the Civic
Wilson, MD, is Medical Director of Honoring Choices Minnesota (http://tinyurl.com/3vbtasl)
and President of the East Metro Medical Society Foundation. He recently
retired from his medical practice in otolaryngology. Dr. Wilson is a
graduate of the University of Minnesota Medical School and a long-time
resident of Saint Paul.
appreciate the invitation to come and chat," Wilson said. "I believe your
organization could be very helpful in educating the community as to what
we are trying to accomplish with Honoring Choices Minnesota."
Learning from the model in La Crosse, Wisconsin
program at Gundersen Lutheran in La Crosse, WI has found significant
improvements in medical care and savings when people make careful,
conscious decisions in advance about the care they would like to have at
the end of life.
with a chronology of their efforts.
Wilson became president of the Ramsey County (now East Metro) Medical
Society. A colleague had become familiar with the Gundersen Lutheran
advance directives program in La Crosse, and thought the Society's
foundation might be interested in pursuing a similar effort. Wilson, new
to the foundation's board and interested in finding a project to work on,
agreed to take on this effort. The foundation board authorized a site
visit, so Wilson made the trip to La Crosse and spent a day observing the
Respecting Choices program at Gundersen Lutheran.
were a number of features that Wilson found appealing, particularly the
effective communication and cooperation across hospitals and the record of
success-90 percent of people that died in La Crosse had health care
directives, and those directives were observed 99.5 percent of the time
Nationwide approximately 20 percent of people have a health care directive
Wilson said, and of those 20 percent having directives, many keep their
directive in an attorney's office or safety deposit box, not readily
assessable by hospital staff.
Wilson the numbers in La Crosse showed that the administrators had
appropriate support structures and effective processes in place to sustain
this program. "Having a carefully thought out health care directive had
become the community standard. This is simply what you did, from the
perspective of both the community's and the doctors' expectations."
result Gundersen experienced a reversal in the data regarding the location
where people died. In the 1990's the majority of people that died in La
Crosse County died in hospitals, Wilson reported. Yet over time this
reversed, and a majority of people died in their homes.
looked at this and saw this was a model that could be used in the Twin
Cities. Over the course of 20 years they had put together training
materials to help train physicians, nurses, families, congregational
leaders and lay people. We saw that we could do this as well."
to the Twin Cities
Wilson's visit to La Crosse, Bud Hammes, program director from Gundersen
Lutheran, visited Minnesota to speak with the foundation directors and
to talk, and we asked the question of our medical foundation: Would the
Twin Cities benefit from this type of program?" Yes, the members
responded. They held another meeting with regional hospital
administrators, and 27 out of 27 attending voted yes. One manager remarked
to Wilson after the meeting that the foundation is the best place to
undertake such an effort, "because there is no single hospital that could
create a metro-wide program beyond the confines of their own hospital
Forming Honoring Choices Minnesota
Choices Minnesota is a collaborative association, Wilson said. The Twin
Cities Medical Society, through its East Metro Foundation, is servingas
the convener and coordinator of the initiative. No one on the roster of
metro area health care organizations is missing from the group. As of this
summer, all major providers have experienced this program at the pilot
heart of the program is the effort to complete a health care directive
through facilitated discussions with an individual and his or her family
members. The family discussions revolve around the critical questions
about treatment decisions that may have to be made at a point in time when
the individual may be unable to participate in those decisions.
most crucial thing is that an individual would have a discussion with
family, appoint an agent to act on his/her behalf, and express how the
person's values and religious convictions should inform decisions-since
you can't predict every specific question that may ultimately arise."
program is underway in the Twin Cities. Fairview is training 18-26
facilitators per month. In the first seven months of the year, Park
Nicollet entered 1,700 Health Care Directives (HCDs) into its information
system. Allina is averaging approximately 1600 HCDs entered into their
medical record per month, for January through June, 2011.
seen at least at a pilot level that if the family has had the discussion
and if the family has a document in their hands it will be followed.
That's why having a culture open to advance care planning is so important.
We're building an infrastructure for this process within the health care
system. There is a long-term public education campaign that runs alongside
the building of the medical infrastructure."
Upcoming coverage of the Minnesota effort
Cities Public Television (TPT) came to us with an idea for a 2-3 year
public engagement program. This public engagement program was similar in
principle to the public engagement program carried out in La Crosse after
medical infrastructure had been installed. We were generously supported by
local foundations, non-profits, insurers and heath care systems. This
began in the summer of 2008 when the 'death panel' rhetoric was at its
wanted to get down to the levels of the individual, so we said: 'It's
reasonable to have these discussions within your family, to have choices
over how things will affect you.'"
Citizens League helped in the effort by carrying out two-hour listening
sessions on the topic with people across the state from various religious,
ethnic, cultural and identity groups. "We felt modeling the types of
conversations and controversies would be helpful. The League has completed
those sessions and they will be writing us a report in 6-8 weeks with
listening sessions revealed participants' notions about the quality of the
end of life, Wilson said. "You'll see in the videos that people talked
about the worst cases that tore families apart, and those that turned out
case he cited, the family knew the patient, a woman, had three months to
live. She went first into home hospice care, then a hospice facility. Pain
management was an issue in her care. The hospice staff over the first few
days gave her a lot of medication that greatly inhibited her abilities.
When her family had discussed this with her ahead of time, she said she
wanted to be as wide-awake as possible so that she could visit with her
family sat down and had a conversation with hospice staff: 'We know this
is your standard of care, but she just wants the top edge of her pain
taken off, so that she can continue to interact.' The hospice workers
lessened the medication and the woman was then able to have the
interaction with her grandchildren that she wanted before she died.
developed a website with a toolkit of video clips, resources, and 'e-vites'
to support and encourage family discussions. I think you'd all be
interested in visiting
www.honoringchoices.org. TPT Channel Two is making a series of six
documentaries on advance care planning and end-of-life issues the program,
to air over the next 18 months."
Strategy for growth: Keep it in the hospitals
question about Medicare, Wilson replied that, "We don't have a position on
Medicare doing this type of program-this is being developed at the
institutional level. It is good for the patients, their families and the
system, and it turns out it is also less expensive, based on La Crosse
figures. La Crosse is one of the lowest-cost cities in the nation for
medical care during the final two years of life.
areas have done this from the top-down; Singapore, British Columbia are
examples of top-down directives being the creative impetus. Our strategy
is fundamentally different. We want this to come through the collaboration
of providers and patients and their families."
Minneapolis and St. Paul the average cost of care for the final two years
of life is a bit below the national average. The numbers are tending to
improve. "But I think that the primary argument for this kind of program
is that it's simply better medical care, better for families and better
for medical teams. If we duplicate the effect of Gundersen there will be a
positive economic effect as well."
worst thing, Wilson said, would be a revival of the "death panels"
rhetoric. So they are hoping to avoid having this end up in legislation.
"Keep it at a family conversation level," he said. "Honoring Choices
Minnesota - It's about the conversation." Consequently they are reaching
out to many groups across the area, including faith, cultural and ethnic
groups to build understanding and commitment.
Question and Answer
there a strong financial disincentive for this kind of treatment limit?
that there would be, Wilson said, but in practice the hospitals frequently
lose money on long-term care at the end of life. There is a hospital
reimbursement system for Medicare that pays a set amount for each
particular defined medical event. There's a payment methodology so that if
you go into a hospital with a particular medical condition there is a
corresponding reimbursement maximum. The problem for the hospital arises
if, when the condition calls for 5 days of treatment, it actually ends up
taking 10 days; then the hospital has 5 days of unreimbursed service.
absence of a clear directive limiting the measures to be taken, the
default of the medical community is to do everything possible to keep the
patient alive. If it takes a family two weeks to come to a decision about
what to do while the patient is in an intensive care facility, that's a
very expensive situation.
hospital administrators, I think, would say that both the health care
system and the patient are best served when the patient is in the most
appropriate medical setting for the acuity of the disorder, whether that
be acute care hospital, transitional care facility or long term care
important thing for everybody in health care, he stressed, is that the
patient is getting the care that is appropriate for him or her at the
What is the incentive for the individual to do this?
An important incentive is the peace of mind resulting from having control,
as best one can, over decision-making about one's care when and if it will
be needed. There is incentive for the family because an agent is appointed
who will make decisions if the patient can't. It is better for the agent
and health care team who know in advance the wishes of the patient, and
smoother for the process when well-informed decisions can be made without
had a number of discussions about putting financial incentives for health
care directives into government programs, and we have steered quickly away
from that approach. In health care if you put in place financial
incentives there will immediately arise an industry to take advantage of
those incentives. We went to the people at the department putting together
health care homes and asked about offering a $10 incentive for completing
a health care directive. They asked in turn if we were crazy. 'We don't
want to create a cottage industry of paper mills turning out rubber stamp
health care directives for $10,' they said. Neither do we. It is about the
conversation with family that results in a useful, helpful family
consensus and document.
How do you know what all the options are for treatments before they
happen-aren't there too many?
That's why these conversations have to be considered as moving targets.
What you consider varies depending on where you are at a point in your
life. If your situation changes-if you go on dialysis, for example, and so
are more prone to kidney problems-all you have to do is make out a new
has developed not only basic advance care planning, but also
disease-specific advance care planning, as well as more particular
questions for specific conditions. In the latter program the family and
physician are able to get a pretty good sense of possible future issues
that a particular medical condition, such as renal failure or congestive
Allina this year in the first six months they've done 1,450 of these
90-minute extensive discussions that got the family talking about
disease-specific treatment plans, medication preferences and so forth.
This is significant progress when you consider that it's taken Gundersen
20 years to get where they are today.
When do you anticipate seeing results?
At Gundersen it was 10-15 years before the results started to become
apparent. They have a few hundred people facilitating these conversations.
We're moving in that direction and are on track to get there.
coming year, Honoring Choices' pilot programs in Twin Cities hospitals
will continue and the public engagement efforts in collaboration with TPT
will attempt to build support and encourage participation. One of the
major barriers to fulfilling the long-term vision, Wilson pointed out, is
that electronic medical records systems do not at present include
end-of-life directive records that are readily available and transferable.
Going forward the program will continue to work toward making advance care
planning the standard of care for all adults and assuring that patients'
choices are both clearly defined and conscientiously respected. He is
optimistic about the program's future.
Thanks all around for
the visit today.