BHCG Monitor: Focus on Health Care Benefits - April 2012

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BHCG Monitor: Focus on Health Care Benefits - April 2012


Advance Care Planning – An Imperative Conversation

Hopefully, most consumers have planned for retirement and probably have a will. But what about planning and sharing health and medical wishes with families and key health care providers – do loved ones and physicians know their wishes? If not, they may be putting them all in the very difficult position of having to make critical health care treatment decisions on their behalf.

Advance care planning, commonly referred to as Advance Directives, is yet another critically important step that consumers can take to be responsible for their own health and health care. In this article we answer the following questions: Why is advance care planning important? What do the terms Advance Directives, Living Wills and Power of Attorney for Health Care mean? We’ll also review two initiatives in Wisconsin concerning advance care planning and plans BHCG has to support its members in addressing this critical issue.

The case for advance care planning

Many people assume that a spouse or adult children automatically have authority to make health care decisions when a family member can no longer communicate their wishes. In fact, in Wisconsin, like most states, there are no statutes or court decisions that give spouses or adult children such authority. The authority of the family to make decisions to stop medical treatment does not exist or is very limited. In Wisconsin, the only way that an individual can be assured that their family will have the authority they need to make health care decisions should they become incapable is to legally appoint them using a power of attorney for health care document.

Beyond the emotional toll on a family wrestling with life and death decisions when a loved one has not provided them clear instructions about their wishes, there is also a considerable economic toll. With no clear cut instructions on how to address a situation where a family member is near the end of their life, health care providers and family members tend to err on the side of doing everything modern medicine can provide to extend life – regardless of the poor quality of life that may result or the costs incurred. Some telling statistics about the costs associated with end-of-life care:

  • In 2009, according to a CBS News documentary, Medicare paid $55 billion just for doctor and hospital bills during the last two months of patients' lives.
  • According to the Centers for Disease Control, a vast majority of Americans say they want to die at home, and yet about 64 percent of those 65 and older died in hospitals and nursing homes in 2009.
  • About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life.
  • An examination of costs in the last year of life (Lubitz & Riley 1993) found that 10-12 percent of the total U.S. health care budget and 27 percent of the annual Medicare budget were spent on care at the end of life. Follow-up studies show this figure has remained constant over the past two decades.

Sorting out the terms: Advance Directives, Living Will, Power of Attorney for Health Care

There is considerable confusion about these terms and perhaps more importantly, confusion about what document(s) a person needs to complete in order to convey their wishes should they be facing a serious medical condition. Advance Directives is a broad term that encompasses any plan, written or oral, regarding future health care decisions. Two of these are a Power of Attorney for Health Care (POAHC) and a living will.  

A POAHC is a legal document recognized by state statute. It allows an individual to appoint another person and an alternate person to make medical decisions if the person becomes incapable of doing so. This legal document also allows you to provide instructions about what type of medical care an individual does and does not want.

In contrast, a living will is a considerably less flexible document. It only allows an individual to provide instructions about when they would not want certain medical care. For most people, the POAHC is the most effective document to complete. It allows another person to make health care decisions if a person becomes incapable of doing so. A POAHC document that meets the statutory requirements in Wisconsin can be downloaded by clicking here.

Respecting Choices – A model for success

In Wisconsin, there is an impressive example of how a community has embraced the issue of end-of-life planning with positive results. Started in 1991, the Respecting Choices initiative in La Crosse has created an improved model of end-of-life planning and decision making. According to the Respecting Choices web site, “The program is unique because it uses an integrated systems approach that not only depended on printed material and videos to educate the community, but also provides the personal assistance of trained staff. This approach is then integrated as the routine standard of care through consistently applied policies and practices.”

The results of this program were dramatic. Again, as cited in the Respecting Choices web site, “Of the 540 adult deaths in the La Crosse community studied from April 1995 until March 1996, Advance Directives had been written by 85 percent of those who died. Of those documents, 96 percent were found in their medical records.”

Today Respecting Choices serves as a model for how to implement end-of-life planning initiatives for 80 other communities across the country. For more information about the Respecting Choices initiative click here.

Wisconsin Medical Society initiative

In the near future, the Wisconsin Medical Society will be announcing an advance care planning project that will give physicians and other health care providers the knowledge and tools to make system improvements that ensure patients make well-informed decisions about wishes for the end of life. The project, which will be modeled after the Twin Cities Medical Society’s Honoring Choices Minnesota, also will provide a process to honor those decisions as care progresses.  According to Dr. Tim Bartholow, a family medicine physician, and the Society’s chief medical officer, “Conversations about health care at the end of life are difficult for all of us, but it is imperative that they happen. It is equally important that patients’ choices are honored by those who care for them.”

For more information about the Wisconsin Medical Society’s advance care planning project, (Respecting Choices) click here.

The BHCG: Taking action to support advance care planning

The BHCG is acutely aware of the critical need for advance care planning. In addition to working with and supporting the Medical Society’s initiative, over the course of the next year, the BHCG intends to put a significant focus on end-of-life planning issues. Specifically, the BHCG intends to support member companies'  efforts to communicate the need for advance care planning with their employees through the development of a turnkey communications program. Additionally, the BHCG is planning an educational event for employer members about this important topic.

All too often patients do not receive the care they want as they approach their last days. Discussing end-of-life care is difficult for everyone involved: health care providers, patients and family members. It is, however, imperative that these discussions happen. “There are no right or wrong decisions when it comes to creating an Advance Directive. What is important is having one that was created through a thoughtful discussion with your loved ones,” says Dianne Kiehl, BHCG’s executive director.

For additional information:

Additional resources are available at the following web site:

Considering the Conversation: A Documentary on a Taboo Subject Co-produced by Wisconsin natives Mike Bernhagen and Terry Kaldusdahl, Consider the Conversation is “an intimate story about the American struggle with communication and preparation at the end of life.”

Honoring Choices Minnesota A partnership of Twin Cities Medical Society and Twin Cities Public Television

Works Cited

(n.d.). Retrieved from Respecting Choices:

Advance Care Planning Project. (n.d.). Retrieved from Wisconsin Medical Society.

Medical Records. (n.d.). Retrieved from Gundersen Lutheran.

Lubitz, J. D., & Riley, G. F. (1993). Trends in Medicare payments in the last year of life. N Engl J Med, 328(15), 1092-1096.

BHCG Monitor: Focus on Health Care Benefits - April 2012