"Respecting Choices" Model Coming to South Carolina

Abstract

The South Carolina Medical Association is now working to follow the lead of physician organizations in Wisconsin, Minnesota, and Virginia, as members plan to implement an early-intervention advance care planning program that has drawn national media attention in recent months.

A product of La Crosse, Wisconsin’s Gundersen Health System, Respecting Choices engages patients in informed discussions about end-of-life decision-making. The paradigm trains non-physician facilitators to guide patients through complex, value-driven considerations within programs staged to individual health. Ninety-six percent of those who die in La Crosse now have advance directives; nationally, 30 percent of adults do. La Crosse has been dubbed in headlines as the “town that talks about death,” and providers across the country now hope their own towns can become the same.

“It was a natural fit, because Respecting Choices is a very physician-friendly organization,” said John Ropp, a family physician serving on the South Carolina Medical Association Board of Trustees. “It makes sense from a clinician standpoint what they’re trying to accomplish.”

Social workers, chaplains and nurses in five South Carolina health systems are expected to begin advance care planning facilitator training in early 2015. The dues-driven association will seek funding from those systems to help finance the estimated $250,000 implementation cost. Funding from private insurers is expected as well.

Members say they realize a physician organization like their own is right to lead such an initiative, and their sponsorship helps remove any perception of conflict of interest.

“It would be really difficult for an insurer or state agency to roll this out, because they would be seen as trying to save money by limiting care,” Ropp said.

Respecting Choices designer and medical ethicist Budd Hammes agrees. “Medical societies stay out of provider competition,” Hammes said. “They represent physicians at all institutions and have clear leadership roles.”

Several medical associations have recently sponsored Respecting Choices initiatives. “Honoring Choices Minnesota” has been the project of the Twin Cities Medical Society since 2010, training 1700 facilitators statewide. Project directors say about 35 percent of Minnesotan adults now have advance directives stored in electronic medical records - a percentage surpassing the national average.

The Wisconsin Medical Society expanded Respecting Choices beyond La Crosse in early 2013, establishing advance care planning pilot sites within six health systems in the Madison-Milwaukee corridor. Three thousand end-of-life conversations have been facilitated in the project’s first year. “Whether it takes ten years or more, we want this to be a routine standard of care,” said John Maycroft, the Wisconsin Medical Society’s director of initiatives. “We may never hit La Crosse numbers, but maybe we can hit 70 or 80 percent.”

This September, the Richmond Academy of Medicine will train 30 Respecting Choices facilitators across three health systems. The Academy voted to back the plan after several members shared concerns about hospice referrals coming too late for patients to realize true benefit. Executive director Deb Love said earlier intervention was considered “more palatable than the current approach- waiting until a crisis develops.”

In South Carolina, it was the Physician Orders for Scope of Treatment (POST) pilot project this spring that exposed association members to the need for earlier advance care planning. POST, similar to an advance directive, is a medical order intended for patients expected to die within one year. “There’s a lot more to it,” Ropp said. “So the question was ‘where do we go next?’”

Facilitators will be trained to speak with patients of all ages and stages of health regarding concerns about end-of-life care and any experiences had with seriously ill loved ones. A Respecting Choices discussion identifies a surrogate decision-maker, someone a patient believes is willing and trustworthy to make medical choices if he or she is unable. Religious and cultural beliefs influencing care choices are also unraveled, and patients often leave facilitations with advance directives completed.

“It’s a way for them to come to their own personal insight about why this is important, what they want to do, and what their values, goals and preferences are based on other experiences,” Hammes said.

Part of the program’s attractiveness, Ropp says, stems from the fact facilitators are non-physicians; they are placed within health systems so busy doctors may refer patients for comprehensive discussions. “Frankly, it’s really hard to have meaningful conversations about this stuff with the time we really have,” he said. “It’s going to take more than doctors to accomplish meaningful things in the community in terms of better end-of-life care.”

Physicians, however, play a crucial role in advance care planning. Ropp believes that doctors nationwide are beginning to realize the value of early end-of-life dialogue and the urgent responsibility they hold to promote it.

“Projects like this really hit at the core values of the physician-patient relationship,” he said. “It involves honest communication, consent and relationships.”