By Gundersen Health System
At Gundersen Health System in La Crosse, WI, advance care planning is the process of communication aimed at helping people understand and articulate their thoughts and preferences for future medical decisions. The process is crucial to help patients receive the best care according to what matters most to them, if a time comes when they cannot make their own decisions.
“Unexpected things happen when we least expect them,” says Danielle Rathke, DNP, RN, Gundersen’s advance care planning director. “The best time to begin to plan and prepare your loved ones is while you feel well — before a health crisis.”
Over the last few decades, the culture in La Crosse has shifted so patients have become open to planning for future healthcare. Now, the typical patient understands the importance and value in having these not easy but important conversations.
In 1995-1996, and again in 2007-2008, data was collected and published to study the percentage of deceased patients in the La Crosse region who had written plans accessible in the medical record and who had evidence that treatment decisions were honored. Gundersen had a high prevalence of planning (85 percent and 90 percent), the documents were accessible (95 percent and 99 percent), and treatment preferences were honored (98 percent and 99 percent).
Gundersen recommends that people review their advance directive every five to 10 years or with a change in health. The system suggests a review using the “five Ds” – each decade, new diagnosis, decline in health, divorce, or death of a loved one. Gundersen has a specific space in the electronic medical record where all ACP-related information is stored and easy to access. Advance care planning is reviewed with annual visits, hospital admissions and other clinical encounters as appropriate. Patients can access ACP information through Gundersen’s patient portal called MyCare as well.
Meaningful conversation about what matters most is the best way to begin planning for future healthcare decisions. For many people, this is not an easy topic to broach. Gundersen Health System provides trained facilitators who ease the process by guiding people and their families through a conversation. Advance care planning facilitators help people reflect on what matters most in their lives and discuss acceptable and unacceptable outcomes should they experience a health crisis.
Chaplains are typically excellent candidates for providing facilitation services. Pastors or parish nurses in the community can also make good facilitators. Gundersen holds both internal and community First Steps facilitation courses. Pre-course requirements take four to five hours before the full eight-hour instructor-led course. Participants leave the course with basic skills for the conversations; ongoing practice leads to mastery. The organization provides mentoring through observation and co-facilitation activities for our facilitators.
“Advance care planning is not just talking about end of life but is about discussing how a person wants to live,” says Elizabeth Cogbill, MD, Gundersen’s advance care planning medical director. “We all have our own definition of quality of life, and we can’t assume that those around us automatically know it. We have to talk about it.”
In addition to assisting with the conversation, facilitators arm people with information, dispel myths, and answer questions. Typically these conversations result in a written plan called an advance directive. Gundersen recommends an advance directive that includes power of attorney for healthcare. Through this document, an individual legally designates a person(s) to speak on her behalf if she becomes unable to communicate her decision and includes instructions for future care.
In Wisconsin the legally designated decision-maker is known as a healthcare agent. A healthcare agent makes decisions based upon the person’s goals, values, and preferences as conferred in conversation and as set forth in an advance directive. The healthcare agent speaks on behalf of a person only when the person cannot speak for himself. An advance directive gives the healthcare agent authority for healthcare decisions but not for financial decisions. (Note the difference from a power of attorney, which allows a designee to execute certain property or financial matters on someone’s behalf — but not make medical decisions.)
“The best way you can prepare the people closest to you to speak on your behalf and to protect them from additional stress during a difficult time is to have the conversation. It’s a gift to your family,” says Rathke. “The conversation has so much value. Without it, there can be confusion, conflict, and guilt in a situation that’s already overwhelming.”
Advance care planning is an ongoing process that must be revisited over time. It’s important to begin when someone is healthy so that if he or she is faced with an illness, this type of planning is not a new concept.
“We provide assistance with planning over the course of a person’s lifetime,” Rathke says. “We begin when people are healthy, and our conversations become more specific when a person develops a serious illness and when a person is nearing the end of life. It is never too early to prepare yourself and loved ones for decisions that may be needed in the future.”
Learn much more about advance care planning online here.
