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A Comparative, Retrospective, Observational Study of the Prevalence, Availability, and Specificity of Advance Care Plans in a County that Implemented an Advance Care Planning Microsystem


Address correspondence to Bernard J. Hammes, C03-006, Gundersen Lutheran Medical Foundation, 1836 South Avenue, La Crosse, WI 54601. E-mail:


OBJECTIVES: To determine whether outcomes have changed over time for a managed, systematic approach to advance care planning (ACP).

DESIGN: Retrospective comparison of medical record and death certificate data of adults who died over a 7-month period in 2007/08 with those of adults who died over an 11-month period in 1995/96.

SETTING: All healthcare organizations in La Crosse County, Wisconsin.

PARTICIPANTS: Five hundred forty adults who died in 1995/96 and 400 adults who died in 2007/08.

INTERVENTION: A systematic ACP approach, Respecting Choices, collaboratively implemented in 1993 and continuously improved in subsequent years.

MEASUREMENTS: Demographic and cause-of-death data were collected from death certificates. Type and content of any advance directive (AD), existence and content of Physician Orders for Life-Sustaining Treatment, and medical treatment provided at the location of death in the last 30 days of life were abstracted from the medical record.

RESULTS: The recent data show a significantly greater prevalence of ADs (90% vs 85%, P=.02) and of availability of these directives in the medical record at the time of death (99.4% vs 95.2%, P<.001) than the data collected over 10 years ago. The new data suggest that quality efforts have improved the prevalence, clarity, and specificity of ADs.

CONCLUSION: A system for ACP can be managed in a geographic region so that, at the time of death, almost all adults have an advance care plan that is specific and available and treatment is consistent with their plan.