National Public Radio recently recognized what we in bioethics had long known — La Crosse, Wis., has the distinction of being the only city in America where just about everyone has an advance directive, a durable power of attorney for health care or living will to speak to their medical wishes if they later lose the capacity to make their own decisions.

NPR credited the efforts of Bud Hammes, the bioethicist on the staff of a La Crosse hospital, who many years ago noted the anguish of families called on by doctors to make decisions on behalf of relatives who had never recorded their wishes earlier. Hammes made it his mission to convince as many local residents as possible that they’d be doing their families a huge favor by having the difficult conversations and making sure everyone knew what they would want in the event of a later medical crisis.

La Crosse’s roughly 96 percent rate of having completed an advance directive stands in contrast, NPR said, to the rest of the country, where it’s more like a third — and even that is an improvement compared previous years when it was a quarter or less.

The NPR report was welcome to people like me who have long admired Hammes’s good work. But NPR nevertheless left out some important parts of the story.

One thing it did not address was how long this whole process took. Hammes first reported success in a paper published in 1998, at which time the “Respecting Your Choices” program had been going on in La Crosse for seven years. So, what we see today in La Crosse reflects at least 23 years of sustained effort.

The sorts of results NPR reported didn’t happen overnight. Hammes and his colleagues had to enlist civic organizations, church groups and many others.

Another important point not in the story was how Hammes initially had to work out a collaboration among four major health facilities in La Crosse. They had to agree on a method to assure that if a patient with an advance directive was admitted to one of their facilities, the directive would immediately be available to the staff. Then, if the patient was later transferred to a different facility, the advance directive document had to follow the patient.

Without closing the loop this way, there was no assurance that a patient who took the trouble to complete an advance directive would actually see it affect later health care choices.

In some cities, competing hospital can’t even agree on the time of day. So, it’s notable that the “Respecting Your Choices” group in La Crosse was able to get this level of cooperation going very early in their process.

In short, the adage about “it takes a village” seems to apply to uptake of advance directives in a community. La Crosse can certainly point the way for other American cities, but no one should imagine that it can happen overnight or not take real work. Which means, of course, that the time to get started is right now.

Dr. Howard Brody is director of the Institute for the Medical Humanities at the University of Texas Medical Branch.

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