Americans would rather not talk about death. When we do, we express hope of dying painlessly at home and surrounded by those we love. Unfortunately, circumstances like cancer, stroke, dementia, frailty, and institutionalization intervene. Today, nearly sixty percent of deaths occur in hospitals. Treatment for patients in their last year of life accounts for more than one-quarter of Medicare spending. Doctors are doing their job (to prolong life); patients and families are doing theirs (to show that “everything possible” was done on behalf of those we love). But often doctors are not talking to patients, patients are not talking to families, and no one is thinking about the kind of death that would be most meaningful and comforting for all.
The Advance Directive, or Living Will, is a tool for beginning the discussion about the way we want our lives to end. The forms can be long and complicated– the one used in our office is 19 pages long– so we developed a Quick Guide for use by patients and doctors. It is one way to foster the discussion between patients and doctors and to assure that the form is completed.
The Medicare Annual Wellness Visit reimburses doctors for having a discussion about the Advance Directive at no charge to the patient. The Gundersen Clinic has lead the country in comprehensive advance care planning; 96% of patients in La Crosse, Wisconsin die with an advance directive compared to 30% nationally. Advance care planning has been shown to improve end of life care and patient and family satisfaction (reduced stress, anxiety, and depression in surviving relatives). It has can also significantly lower levels of Medicare spending, lower the likelihood of in-hospital death, and increase the use of hospice care. The “good death” that patients seek really depends on our ability to manage their symptoms, avoid a prolonged death, provide a sense of control, relieve the burden on families, and strengthen relationships among them.