Bernard “Bud” Hammes, PhD, has spent a lot of time on the phone lately. The balding, spectacled but tireless medical ethicist for La Crosse, Wisconsin, Gundersen Health System has been enthusiastically fielding calls from medical societies, health executives and policymakers nationwide, wondering if they can turn their system or town into one like his own—dubbed in recent headlines as “The Town that Talks About Death.”

Since 1991, Dr. Hammes has been refining his Respecting Choices program, engaging patients in informed discussions about end of life decision-making. More than two decades later, he is witnessing tremendous benefits. Ninety-six percent of those who die in La Crosse have advance directives; nationally only 30% of adults do. “It’s a part of the social fabric here,” Dr. Hammes said of La Crosse, where studies show Respecting Choices has led to the high prevalence in honoring patient preferences, reduced use of hospital services, and no change in mean length of life.

The program is no silver bullet, he acknowledges, calling it instead, “a central tool in the complex tool kit for improvement of health systems and the care of patients.” However, that “central tool” for care may be more aptly described as an axe when applied to health spending. According to the Dartmouth Atlas of Health Care, La Crosse spends less on patients at the end of life than any city nationwide. A finding like that is something health leaders notice, since the Affordable Care Act encourages simultaneous spending reduction and quality improvement.

“We used to shy away from cost questions,” Dr. Hammes said. “We are certainly more comfortable saying something improves care. That it saves money is a blessing and unexpected event, and it gives us the ability to carry out this work.”

It turns out that when asked, most patients opt against high-intensity end-of-life care. But more than a quarter of Medicare spending is spent on just that. The particulars of patient preferences aren’t what matters to Dr. Hammes. What matters is that patients are asked what those preferences are, and that they are honored.

“Chaplains, social workers and nurses are among those being trained within health systems to guide patients in determining what they value at the end of life.”