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S. HRG. 113–801 

RENEWING THE CONVERSATION: RESPECTING 

PATIENTS’ WISHES AND ADVANCE CARE 

PLANNING 

HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

WASHINGTON, DC 

WEDNESDAY, JUNE 26, 2013 

Serial No. 113–7 

Printed for the use of the Special Committee on Aging 

( 

Available via the World Wide Web: http://www.fdsys.gov 

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(II) 

SPECIAL COMMITTEE ON AGING 

BILL NELSON, Florida, Chairman 

RON WYDEN, Oregon 

ROBERT P. CASEY JR, Pennsylvania 

CLAIRE MCCASKILL, Missouri 

SHELDON WHITEHOUSE, Rhode Island 

KIRSTEN E. GILLIBRAND, New York 

JOE MANCHIN III, West Virginia 

RICHARD BLUMENTHAL, Connecticut 

TAMMY BALDWIN, Wisconsin 

JOE DONNELLY Indiana 

ELIZABETH WARREN, Massachusetts 

SUSAN M. COLLINS, Maine 

BOB CORKER, Tennessee 

ORRIN HATCH, Utah 

MARK KIRK, Illinois 

DEAN HELLER, Nevada 

JEFF FLAKE, Arizona 

KELLY AYOTTE, New Hampshire 

TIM SCOTT, South Carolina 

TED CRUZ, Texas 

KIM LIPSKY, Majority Staff Director 

PRISCILLA HANLEY, Minority Staff Director 

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CONTENTS 

Page 

Opening Statement of Chairman Bill Nelson ........................................................ 1 

Prepared Statement ......................................................................................... 10 

Opening Statement of Ranking Member Susan M. Collins ................................. 1 

Prepared Statement ......................................................................................... 4 

Statement of Senator Ron Wyden .......................................................................... 7 

Statement of Senator Mark Warner ...................................................................... 8 

Statement of Senator Joe Donnelly ........................................................................ 9 

Statement of Senator Elizabeth Warren ................................................................ 11 

PANEL OF WITNESSES 

James Towey, Founder, Aging with Dignity and President, Ava Maria University ......................................................................................................................... 12 

Harriet Warshaw, Executive Director, The Conversation Project ....................... 23 

Amy Vandenbroucke, Executive Director, National Physician Orders for LifeSustaining Treatment and Paradigm Task Force ............................................. 29 

Gloria Ramsey, RN, Associate Professor, Uniformed Services University of 

the Health Sciences .............................................................................................. 44 

APPENDIX 

PREPARED WITNESS STATEMENTS AND QUESTIONS FOR THE RECORD

James Towey, Founder, Aging with Dignity and President, Ava Maria University ......................................................................................................................... 15 

Harriet Warshaw, Executive Director, The Conversation Project ....................... 25 

Amy Vandenbroucke, Executive Director, National Physician Orders for LifeSustaining Treatment and Paradigm Task Force ............................................. 32 

Questions submitted for Ms. Vandenbrouck ......................................................... 68 

ADDITIONAL STATEMENTS FOR THE RECORD

Prepared statement of Senator Sheldon Whitehouse ........................................... 59 

Robert Fine, MD, FACP, FAAHPM, Clinical Director, Office of Clinical Ethics 

and Pallative Care, Baylor Health Care System ............................................... 77 

Ashley Carson Cottingham, Director of Policy and Advocacy, Compassion 

and Choices ........................................................................................................... 82 

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RENEWING THE CONVERSATION: 

RESPECTING PATIENTS’ WISHES 

AND ADVANCE CARE PLANNING 

WEDNESDAY, JUNE 26, 2013 

U.S. SENATE, 

SPECIAL COMMITTEE ON AGING, 

Washington, DC. 

The Committee met, pursuant to notice, at 2:04 p.m., in Room 

SD–124, Dirksen Senate Office Building, Hon. Bill Nelson, Chairman of the Committee, presiding. 

Present: Senators Nelson, Wyden, Whitehouse, Blumenthal, Donnelly, Warren, Collins, and Ayotte. 

Also present: Senator Warner. 

OPENING STATEMENT OF SENATOR BILL NELSON, CHAIRMAN 

The CHAIRMAN. Good afternoon. We have established a new kind 

of procedure here. Sometimes, we give opening statements. Sometimes, we do not. Sometimes, I turn to the most junior members 

of the committee. 

[Laughter.] 

And I am going to have Senator Collins start out and then I will 

make some comments. 

OPENING STATEMENT OF SENATOR COLLINS 

Senator COLLINS. First of all, thank you, Mr. Chairman. This is 

typical of how gracious you are and the bipartisan manner in 

which we jointly run this committee, even though you are the 

Chairman and I always recognize that fact. 

I want to thank you for calling this hearing to discuss the importance of advanced care planning and to examine ways to improve 

how we care for people at the end of their lives. These are critical 

issues that at some point will confront each and every one of us 

and I commend the Chairman for focusing the committee’s attention on them today. These issues also have long been of personal 

interest to me. One of the first bills that I introduced as a new Senator was called the Compassionate Care and Planning Act, and I 

introduced it with Senator Jay Rockefeller way back, I think, in the 

late 1990s. 

Noted health economist Uwe Reinhardt once observed that Americans are the only people on earth who believe that death is negotiable. Advances in medicine, public health, and technology have 

enabled more and more of us to live longer and healthier lives. 

When medical treatment can no longer promise a continuation of 

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life, however, patients and their families should not have to fear 

that the process of dying will be marked by preventable pain, 

avoidable distress, or care that is simply inconsistent with their 

values and their needs. 

Unfortunately, most patients and their physicians do not currently discuss death or routinely make advance plans for their endof-life care. As a consequence, about one-quarter of Medicare funds 

are spent on care at the end of life that is geared toward expensive 

high-tech interventions and rescue care. While most Americans say 

that they would prefer to die at home, studies show that the vast 

majority still die in institutions, where they may be in pain and 

where they may be subjected to high-tech treatments that merely 

prolong their suffering. 

We are making some progress in meeting the wishes of those at 

the end of their lives. More people over age 65 are dying at home 

and in hospice care and fewer are dying in hospitals, and I want 

to make clear that for some people, dying in the hospital is the 

right choice and the right option. But we should be respecting individuals’ wishes. 

At the same time, a recent study published by the Journal of the 

American Medical Association found that end-of-life care continues 

to be characterized by aggressive interventions. Increasing numbers of patients are receiving care in an intensive care unit in their 

last month of life, and a growing number are shifted back and forth 

between different care sites in their final three months. 

Moreover, while the study found that hospice use has increased, 

more than 28 percent of hospice patients were enrolled for three 

days or less. I was astonished by that statistic, because I always 

thought hospice was supposed to be for the last six months, not the 

last three days. 

Clearly, there is more that we can do in this country to improve 

the way that we care for people at the end of their lives. Advance 

care planning has been shown to increase satisfaction not only for 

the person who is dying, but for the family members, as well, and 

it improves health outcomes because people with advance directives 

are more likely to get the care that they want in the setting they 

prefer and avoid the care that they do not want. 

Still, while 93 percent of Americans say that advance care planning should be a priority, only about a third of us have completed 

an Advance Directive. 

I mentioned the bill that I introduced in 1997 with Senator 

Rockefeller. It was intended to facilitate the discussions about endof-life issues with physicians and other health care providers and 

encourage advance care planning. It required that every Medicare 

beneficiary receiving care in a hospital, nursing home, or other 

health care facility be given the opportunity to discuss end-of-life 

care and the preparation of an Advance Directive with an appropriately trained professional. It also required that if the patient 

had an Advance Directive, it must be displayed in a prominent 

place in the medical record so that everyone caring for the person 

could clearly see it. And last but certainly not least, it provided 

Medicare coverage for advance planning consultations between patients and their physicians. 

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Mr. Chairman, patients and their families should be able to trust 

that the care that they receive in their final days is not only of 

high quality, but also consistent with their values, their wishes, 

and desire for autonomy and dignity. This issue, I know, has been 

a high priority for you, Mr. Chairman, for many years, as well. And 

again, thank you for calling this important hearing. 

[The prepared statement of Senator Collins follows:] 

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The CHAIRMAN. Senator Wyden. 

OPENING STATEMENT OF SENATOR WYDEN 

Senator WYDEN. Thank you very much, Mr. Chairman. Like colleagues, I am under the gun, but Senator Warner was here before 

me. 

Senator WARNER. Please go ahead. 

Senator WYDEN. Are you sure? 

Senator WARNER. I am not even on the committee. He is letting 

me come. 

Senator WYDEN. Oh, my goodness. Well, first of all, let me thank 

you, Mr. Chairman and Senator Collins, for your good work on this 

issue. This is about making sure that our people have all the 

choices they want, that they can get the services they need when 

they need them. And I think it is important to set out right at the 

outset that the good and bipartisan work that Chairman Nelson 

and Senator Collins are doing is the opposite of rationing. This is 

the opposite of rationing. They are expanding services to vulnerable 

people and I commend them for it. 

Mr. Chairman, if I could, I just would like to introduce briefly— 

we have got an Oregonian here who is part of a pioneering effort. 

She is the leader in Oregon but also the national leader of a very 

important program called POLST, and it stands for Physician Orders for Life-Sustaining Treatment. Ms. Vandenbroucke is here to 

tell the committee about POLST, which is an approach to make 

sure that we can again emphasize the wishes of the patient, that 

the patient is in the driver’s seat in order to get the kind of care 

that they deserve. 

It is a holistic method of planning for end-of-life care and also incorporates a specific set of medical orders that ensure that the 

wishes of the patients are being honored. And as we will hear from 

Ms. Vandenbroucke, it also helps to expand conversations with 

family members and patients and others so that everybody is trying to think through what kinds of options and the extent of care 

they would like in various kinds of situations. 

And as a result of those conversations, patients can elect to create a POLST form, which translates their wishes into actionable 

medical orders. The form assures that professionals are going to 

provide only the treatments that patients themselves wish to receive and are in keeping with the goals of their program. 

Ms. Vandenbroucke has a J.D. from DePaul, her undergraduate 

degree from Bucknell. We are very glad you are here. 

I will only close by way of saying, Mr. Chairman, I think it is 

particularly timely that you are looking now as we think through 

what the next steps are in health reform. I was very pleased that 

as part of the Affordable Care Act, we were able to get something 

included that, for the first time, people who sought hospice care 

would not have to give up the option of curative care. Again, the 

opposite of rationing. 

So I just commend you, Mr. Chairman, and appreciate your letting me sort of parachute in here for a few minutes to make an 

opening statement, and Ms. Vandenbroucke, we are very proud 

that you and the POLST program are being featured today and we 

thank you, Mr. Chairman. 

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The CHAIRMAN. And, Ms. Vandenbroucke, you realize that your 

Senator from Oregon is the next Chairman of the Senate Finance 

Committee. 

Ms. VANDENBROUCKE. I did not. Thank you. 

The CHAIRMAN. Senator Warner. 

OPENING STATEMENT OF SENATOR WARNER 

Senator WARNER. Well, thank you, Mr. Chairman and Ranking 

Member Collins. I also appreciate the courtesy. 

I am not a regular member of the Aging Committee, but feel this 

is one of the most important issues we have got to address. I have 

tried to address it as a Governor and as a Senator, but also as a 

son in a family where my mom had Alzheimer’s for ten years. The 

last nine years, she did not speak. And our family did not grapple 

and do it right and we know the anguish that particularly my father and my sister, who were there 24–7 as caregivers, went 

through as we went through her final days. 

I want to pick up where Senator Collins’ comments were, because 

we are very much dovetailing that 93 percent of Americans who 

say advance planning ought to be part of our health care system. 

And what I also emphasize with Senator Wyden is this is not about 

rationing. This is about expanding options and honoring people’s 

choices. 

And picking up again where Senator Collins is, during the last 

two Congresses, I have had legislation, the Senior Navigation and 

Planning Act, which helped to try to grapple with a lot of the very 

same issues. How do you get that consultation? How do you make 

sure directives are honored across State lines? How do you rationalize something that is still a patchwork? 

This year, I have been working with my colleague and good 

friend Senator Johnny Isakson from Georgia, where we are reworking and revising the language, and we are not quite ready yet, but 

we do hope in the next couple of weeks to introduce the Care Planning Act, changing the name, as well. And echoing what everybody 

has said, it is to align the care people receive with the care they 

want, no more and no less. The Care Planning Act is not going to 

try to fix all the challenges of advanced illness care but has targeted an effort that people, I think, will most benefit from, which 

is a planning process for people with advanced illnesses. 

These are the people who have the greatest need to, one, just understand their disease and what the potential outcomes and 

timelines are; think about their goals, values, and preferences, not 

only with medical professionals, but oftentimes with their faith 

leaders; three, choose in that setting with that consultation the 

care options that reflect their goals, values, faith, traditions, and 

preferences. And then, when they have made that choice, to find 

a way to document that plan, and that, again, we have an enormous quilt work of even the term ‘‘advance directive’’ is only a partially used term in terms of different States do not even have that 

terminology. 

This legislation will also shore up the Patient Self-Determination 

Act by requiring providers to provide qualified assistance to individuals who want help and by requiring discharge planners to assure that that care plan travels. Too often, we have somebody who 

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may have had some advance directive in one State, but family 

members or others, they end up in a hospital in another State and 

their wishes are not respected. Some of the most fascinating conversations I have had at some time have been with hospital system 

operators, and you get them in a closed room and they will acknowledge that this is not handled in an appropriate way. 

I remember, as well, before I close here, that I had a series of 

meetings with faith leaders, and I remember one minister at one 

point saying, acknowledging that they were pretty good about the 

business of taking people through life and they were pretty good 

about people in the afterlife, but they did not really have a very 

good job of taking people through the transition. So we do think— 

at least I believe—that faith leaders have an important role to 

play. 

So I want to again thank the Chairman and the Ranking Member for holding this important hearing and I look forward to hopefully having the opportunity to participate. 

The CHAIRMAN. Senator Donnelly. 

OPENING STATEMENT OF SENATOR DONNELLY 

Senator DONNELLY. I am happy to participate in this and ready 

to listen to our witnesses. 

The CHAIRMAN. Okay. And I, too, and without objection, my 

opening statement will be entered into the record. 

[The prepared statement of Chairman Nelson follows:] 

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The CHAIRMAN. I think it is worth noting that only 29 percent 

report having a living will that states what their wishes are in endof-life care, and that was one of the reasons I had a little bit to do 

with when Ron Wyden and I were doing, in the Finance Committee, the health care bill, of getting in there where there would 

be a consultation on advance directives. And what we got in the bill 

was that that was going to occur on the first consultation with regard to Medicare, when a person became eligible for Medicare. But 

since then, we have tried to get CMS to put the advance care planning as a part of an annual consultation and CMS removed it. We 

also want to get the Department of HHS to update its research on 

advance directives. 

So, we have a star-spangled board here of witnesses to talk to 

us, and first, we are going to hear from Jim Towey. He served in 

official positions. He has been on the staff of Senator Bob Graham. 

He served as the Director of the White House Office of Faith-Based 

and Community Initiatives. He has been the president of a small 

Catholic college in Pennsylvania. He is now the President of Ave 

Maria University, which is near Naples, Florida. He is a Floridian 

and, in the fairness of disclosure, he is one of my dear personal 

friends who uniquely brings to this discussion today the creation of 

an advance directive called Five Wishes, which is distributed 

around the country. 

We also have Harriet Warshaw. She is the Executive Director of 

The Conversation Project. It is dedicated to helping people talk 

about their wishes for end-of-life care. 

And then we have, as Senator Wyden has already introduced, 

Amy Vandenbroucke, Executive Director of the National Physician 

Orders for Life-Sustaining Treatment Paradigm Task Force. And so 

you bring another unique perspective. 

And then we have Gloria Ramsey, a Registered Nurse, an attorney. Dr. Ramsey is recognized nationally for her leadership in the 

areas of end-of-life care, health disparities, working with vulnerable populations, particularly African Americans and disabilities. 

Dr. Ramsey, instead of reading a prepared statement, I would appreciate it, after you listen to the other three testimonies, which 

will all be of about five minutes in length, if you would comment 

on what you have heard and provide your expertise as a nurse and 

a medical researcher. 

And we have been joined by the very happy and smiling senior 

Senator from Massachusetts. 

[Laughter.] 

Senator WARREN. Yes. 

The CHAIRMAN. Senator Warren, would you like to make a statement, and we are ready to start with our witnesses. 

OPENING STATEMENT OF SENATOR WARREN 

Senator WARREN. Thank you very much. I appreciate it, and I 

apologize for being late. We have activities, and I am going to have 

to excuse myself before we are all through. This is also Senator 

Cowan’s last day and he will be making his remarks from the 

floor—— 

The CHAIRMAN. Yes. 

Senator WARREN [continuing]. So I will be joining him. 

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But I do want to thank you and I want to thank Ranking Member Collins for scheduling this hearing and for reopening the conversation about advanced planning for medical treatment. 

Too often in today’s health care system, medical care is focused 

on treating a disease, not on helping an individual patient. It used 

to be that a family or town doctor would treat a person for most 

of their lives for any medical issue. People and their doctors built 

up strong bonds over time and physicians knew their patients as 

unique individuals. 

Advancement in science and medicine gradually caused more and 

more doctors to begin specializing and only treating certain diseases or certain parts of the body, and now, according to the CDC, 

only 56 percent of office visits are to a primary care doctor. Patients, especially seniors, see several specialty doctors each year 

that focus on different aspects of the individual’s clinical needs. 

So, we are slowly gaining evidence that coordination among doctors giving specialized care can improve a patient’s quality of life 

and keep people healthy longer. I am proud that Medicare demonstrations like the Care Management Program at Massachusetts 

General Hospital are contributing to this evidence and improving 

our outcomes for seniors. Through the Affordable Care Act, we are 

encouraging even more coordinated care through medical homes 

and Accountable Care Organizations. 

But in all of the talk about improving coordination and quality 

in health care, I think we have missed something vitally important, 

something we used to know way back when we had only one town 

doctor. Patients need to be treated like whole people, people with 

loved ones and families, people with dignity and values, not like a 

collection of parts and problems. Somehow, we need to make sure 

that people are still being heard in medicine. 

So I am looking forward to the testimony of our witnesses today, 

hearing about the tools that we have available to help patients participate in medical decision making along with their physicians and 

their loved ones, and about what stands in our way so we can begin 

to work through the barriers and ensure that our seniors’ voices 

are being heard. 

I want to thank you all, and again, thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Warren. 

Senator Ayotte, we are already teed up, ready to go, but we want 

to hear any comments that you have prior to their testimony. 

Senator AYOTTE. I will just wait for the questions. Thank you 

very much for this hearing. 

The CHAIRMAN. Yes, ma’am. 

Okay. Mr. Towey. 

STATEMENT OF H. JAMES TOWEY, FOUNDER, AGING WITH 

DIGNITY, AND PRESIDENT, AVE MARIA UNIVERSITY, AVE 

MARIA, FL 

Mr. TOWEY. Thank you, Mr. Chairman and members of the committee. It is an honor to be here before you. I am happy to be the 

warm-up act for this distinguished panel, and it is also good to be 

back working here in the Senate after working for Senator Hatfield 

seven years. I was here when the Hart Office Building opened, so 

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for me to be here before the Aging Committee is also appropriate. 

It is holding up better than I am. 

[Laughter.] 

But getting old or becoming ill is not a curse. It is part of life, 

with its own unique blessings and demands, and people should not 

dread old age. But why do so many? In part, I think it is because 

our health care system has turned dying into a medical moment 

and has many who are ill feel powerless, as though they are objects 

on some health care conveyor belt. So dying in America is too often 

characterized by poor pain management, loneliness, and spiritual 

starvation. 

From the beginning, Aging with Dignity was an advocate for consumers and individuals, particularly the disabled and the poor, 

who had the most at stake, arguably, when it comes to preserving 

their fragile human dignity. From the day in October 1998 when 

the late Eunice Kennedy Shriver and I launched Five Wishes, I 

have witnessed firsthand the need for people to have advance directives and also their reluctance to engage in discussions with family 

members and medical personnel about their wishes during times of 

serious illness. 

So I would like to turn to the topic of advance care planning first 

by citing some of my thoughts on how it came historically. Of 

course, when it started with Living Wills, very few used them and 

they were written in language that was beyond their reach, often 

by lawyers and individuals with graduate educations. And so you 

saw that this led to the Patient Self-Determination Act, which was 

a very important act of Congress in 1990 and placed the primary 

role of decision making with the patient and his or her designees. 

Over the past 15 years or so, advance care planning policies generally improved in ways strengthening patient rights, and I think 

Five Wishes has been part of that nationally. When I began this 

project with Five Wishes, there were 17 States that required you 

to use a mandatory form, and now there are only eight States, and 

Charlie Sabatino here from the American Bar Association has been 

a real leader in that movement. But what has often happened 

seems to fly in the face of the Patient Self-Determination Act and 

what happens with the protection of patient wishes. 

So I think that while we have seen progress with advance care 

planning, we are also seeing novel improvements and novel challenges. Certainly, POLST has a lot of promise, and I commend the 

work of my colleague here in advancing POLST, because unlike advance care directives, POLST does not require interpretation. It is 

an actionable medical order. And I think that that is great. I think 

for you to have a physician order in place during times of serious 

illness is important. And I think that we also have to be very mindful that if you have POLST used in situations other than when individuals might be in their last year of life, you could run into differing opinions on its usefulness, especially whether a patient’s 

family members were consulted or not, because I think there is a 

lack of consensus on how far upstream POLST can be used and 

should be used and whether there are other concerns that would 

be of importance to Congress. 

So I am going to raise, simply, five points really quickly on 

POLST. I think that the order should clearly note it is intended for 

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people diagnosed with a life-threatening illness that could lead to 

their death within the next year. That is how POLST began. I 

think it is important to keep it moored to that. 

I think the order should include space to describe qualifying conditions and diagnosis, so if the patient is seen also by another physician in the future, it is easier to determine the qualifying conditions and the wishes of the patient. 

I think that the order should note who discussed this with the 

patient. 

I think, also, POLST should not deny the rights of health care 

surrogates and the individual’s right to designate an individual to 

speak for them when they cannot speak for themselves. 

And, of course, it should not be effective indefinitely. 

Finally, I would like to simply say to this committee that I applaud your leadership, Mr. Chairman. Back in 2005, when you first 

sponsored legislation to add advance care planning as one of the 

items discussed in the ‘‘Welcome to Medicare’’ visit, and I urge your 

continued efforts and success. We know that this can become a real 

flash point in the public square. It happened with the Affordable 

Care Act. It could happen again if there is not a thoughtful discussion like we are seeing today by this committee. 

Finally, I would just like to simply say in the way of recommendations that I hope that you consider national legislation to 

affirm the Patient Self-Determination Act, that you make advance 

care planning consultations reimbursable, that you members lead 

by example and have yourselves and your family members and 

staff members availed the opportunity to do advance care planning. 

I am happy to provide Five Wishes. You will not have to disclose 

it on a gift form. We give them away free when needed. And, also, 

I am hoping that as POLST is developed and further integrated in 

our health care systems, that it is done in a way that stays true 

to why it was introduced in the first place, which I think was a 

necessary improvement on helping families get the kind of end-oflife care they want in a care setting. 

So with that and my time up, I want to simply thank you for this 

opportunity to come before this committee and to participate in this 

discussion. 

[The prepared statement of Mr. Towey follows:] 

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The CHAIRMAN. Thank you, Mr. Towey. 

Ms. Warshaw. 

STATEMENT OF HARRIET WARSHAW, EXECUTIVE DIRECTOR, 

THE CONVERSATION PROJECT 

Ms. WARSHAW. Thank you. And on behalf of Ellen Goodman, who 

unfortunately cannot be here because she is in Barcelona today at 

an international health care conference, and our Board of Directors, I would like to extend our appreciation to the committee for 

inviting us here today. 

The Conversation Project is a national public engagement campaign dedicated to helping people talk about their wishes for endof-life care. We have a simple but audacious goal, to assure that 

everyone’s end-of-life wishes are expressed and honored. 

The Conversation Project grew out of Ellen’s personal experience 

with her mother’s journey through the health care system. It was 

a journey that Ellen was not prepared for, filled with many decisions about what kind of care her mother would need since her 

mother was no longer able to make these decisions for herself. 

Ellen was very close with her mom. They talked about everything. 

But the one conversation they never had was how her mother 

wanted to live at the end of her life. 

After her mother had experienced what Ellen would call a ‘‘hard 

death,’’ leaving Ellen filled with uncertainty about what her mom 

might have wanted, Ellen began telling her story to her friends. To 

her surprise, she learned that others had similar experiences with 

their loved ones. Ellen, being Ellen, she looked for a path to see 

how she could improve the way others experienced the death of a 

loved one. 

Ellen reached out to a group of colleagues and concerned media, 

clergy, medical professionals, to share stories of good deaths and 

hard deaths within their own circle of friends. They realized that 

the difference between the two experiences often hinges on whether 

or not they had had the conversation. The consensus from this 

group was that although some progress had been made in the field 

of end-of-life care over the past 30 years, major change would not 

occur until there was pressure from the outside pushing the health 

care system, respectively, to be receptive to and solicitous of people’s wishes for their end-of-life care. 

From this discussion, The Conversation Project emerged as a 

grassroots engagement campaign to change the cultural norm from 

not having the conversation to having the conversation around the 

kitchen table with our loved ones long before there is a medical crisis. To do this, we have embarked on a three-part strategy using 

traditional and new media, collecting stories of good deaths and 

hard deaths to share with others, and to make The Conversation 

Starter Kit tool accessible to people where they live, where they 

work, and where they pray. 

Our hope is that our work will give people the confidence and 

courage to have the conversation about their end-of-life wishes, 

first with their families and then with their health care providers, 

long before there is a health care crisis. 

We have been overwhelmed by the public’s response to The Conversation Project. Since our official launch in August of 2012, our 

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story has been covered by 200 news outlets, including the New 

York Times, the Wall Street Journal, ABC News and World Report. 

Our innovative Web site has been visited by over 100,000 people 

in the first six months, and strikingly, almost 50 percent of those 

who have visited the site have downloaded the starter kit and 

other tools. We have been asked to speak in front of national, 

State, and local organizations, businesses, and health care communities. 

What we have learned during the past ten months is that we 

have touched a tender nerve within the American public. There is 

a deep desire to have end-of-life conversations with our loved ones, 

but people do not know how to begin. This disconnect is consistent 

with the findings of the California Health Care Foundation, which 

found that 60 percent of people say that making sure that their 

family is not burdened by the tough decisions is extremely important. Yet, 56 percent have not communicated their end-of-life wishes to their loved ones. 

We know that in Massachusetts, 17 percent of people have had 

end-of-life conversations with their physician. And in California, 

only seven percent. As a result, while 70 percent of people say they 

prefer to die at home, surrounded by their loved ones, the reality 

is that 70 percent are spending their last days in hospitals and 

other health care facilities. 

We have learned that our goal that people expressing end-of-life 

wishes resonates with communities across the country. We have 

been welcomed into California, into Contra Costa County, to work 

with medical societies, businesses, faith-based communities, to 

make the county conversation ready. We have been asked to convene and speak at educational forums in Boulder, Colorado, that 

was started by residents and in a forum that had over 300 residents in attendance. We have spoken at day-long forums at Wake 

Forest University sponsored by the Medical School, the Divinity 

School, and the Center for Bioethics. And there is now a pipeline 

of communities from the State of Rhode Island, to Kennebunkport, 

Maine, to Akron, Ohio, to Chicago, Reno, Tucson, Portland, Oregon, 

and the State of Hawaii, all who want to initiate The Conversation 

Project. 

One thing is for sure. No matter where we live, no matter what 

side of the political aisle one sits on, we have, each of us, experienced, or will experience, the death of a loved one as well as our 

own mortality. The question for each of us is what we want for our 

care towards the end of our life and how we are going to assure 

that the wishes of our loved ones and ourselves will be expressed 

and honored. We believe that the best place to start is around the 

kitchen table, having an honest and open conversation with those 

we love. Our simple transformative goal is that we will be asking, 

have you had the conversation, and hear in response a resounding, 

‘‘Yes.’’ 

And so, our question to each of you here today, respectfully, is 

have you had the conversation? Thank you. 

[The prepared statement of Ms. Warshaw follows:] 

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The CHAIRMAN. I have had part of the conversation. 

[Laughter.] 

Ms. WARSHAW. We will help you with the other part. 

The CHAIRMAN. And, having gone through the loss of a couple of 

family members recently, I cannot say enough good things about 

hospice and especially when you try to create the environment that 

you are speaking about—— 

Ms. WARSHAW. Absolutely. 

The CHAIRMAN [continuing]. At home, surrounded by the family 

and the loved ones, and that, in what is otherwise a painful experience, is a positive experience. 

Ms. Vandenbroucke. 

STATEMENT OF AMY VANDENBROUCKE, EXECUTIVE DIRECTOR, NATIONAL PHYSICIAN ORDERS FOR LIFE-SUSTAINING 

TREATMENT PARADIGM PROGRAM 

Ms. VANDENBROUCKE. Thank you. Even though he is gone, I 

want to thank Senator Wyden for his kind introduction. 

Chairman Nelson, Ranking Member Collins, and other distinguished members of the committee, thank you so much for having 

me here today. My charge is to describe the POLST Program to 

you. 

As you have heard, POLST stands for Physician Orders for LifeSustaining Treatment and is a specific set of medical orders that 

document the treatments that a patient does or does not want in 

the time of a medical crisis. As detailed in my written testimony, 

it provides orders to health care professionals, including emergency 

personnel, on resuscitation, other medical interventions, antibiotics, 

and artificially administered nutrition. 

The POLST Program is not just a specific set of orders on a form. 

It is also an approach to end-of-life care planning based on conversations between patients, health care providers, and loved ones. 

It was created over 20 years ago by a multi-professional task force 

convened by the Center for Ethics at Oregon Health and Science 

University in Portland, Oregon. POLST was subsequently adopted 

by Oregon’s medical profession, ensuring that health care professionals could honor the treatment preferences of patients diagnosed 

with serious advanced illness, regardless of where the patient is 

during an emergency. 

The POLST Paradigm Program has developed through grassroots 

approach in some States, like Oregon, and through State legislation and regulation in others. In 2004, the National POLST Paradigm Task Force was created to develop a set of standards for 

POLST Programs. The Task Force is charged with endorsing programs when they have proven that their program falls within those 

standards. Currently, we have 16 States that have endorsed programs and we have 25 States that are working towards this endorsement. 

The Task Force also mentors States developing POLST Programs, States like Maine, Senator Collins. Thanks to the Retirement Research Foundation, Maine’s coalition received a three-year 

grant to develop their POLST Program in accordance with the national standards, and my predecessor, now me, has received funding to formally mentor Maine. And through this, they have been 

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able to develop their program, and this year, I will be helping them 

submit their application for endorsement. There are several other 

States that also receive funding, such as Florida, Pennsylvania, 

Rhode Island, New York, West Virginia, Connecticut, Tennessee, Illinois, New Hampshire, and others. 

In Mr. Towey’s testimony, you did hear about advance directives, 

and in my written testimony, I describe the detail between—the 

differences between POLST and advance directives, but I want to 

highlight two here. 

First is the target patient population. While all competent adults 

should be encouraged to have advance directives, the POLST form 

is not appropriate for everybody. It is only when a patient is diagnosed with a serious advanced illness that a POLST form would be 

appropriate. For those patients, they are able to consider their specific diagnosis and prognosis and their goals of care and then complete a POLST form so that they have standing orders for emergent or future medical care reflecting those goals. 

The second is that this is a medical order signed by a health care 

professional giving orders. POLST forms turn the wishes expressed 

in an advance directive into action as a medical order. 

Max’s story, which I included in the written testimony, is a great 

example of when an advance directive is not enough. He had clearly documented his decisions on the treatments he did not want to 

receive when he was diagnosed with progressive heart condition in 

an advance directive, but when he collapsed as a result of that condition, the EMTs responding were unable to honor his wishes because they did not have a medical order. And for EMTs, when they 

are responding in a medical emergency in Oregon, they need to 

have medical orders. Otherwise, they have to do everything possible to attempt to save a person’s life. And the POLST form can 

convey those orders. Max’s death would have been very different if 

the responding EMTs had had the POLST orders to direct his care. 

He would have been allowed to have the natural, peaceful death 

that he so greatly desired, and his family would have had the comfort of knowing that his wishes were honored and respected. 

There is still work to be done. As you likely know, electronic 

medical record systems can be complicated, and even though a 

record can be in the system, it may not be easily located. Although 

POLST is primarily a State effort, we invite the committee’s endorsement of a uniform standard for electronic medical record systems to ensure that documents that are needed at the time of an 

emergency to honor a patient’s autonomy are easily found, ideally 

with a single click. 

Four final observations about POLST. First, comfort measures 

are always provided. In fact, research now shows that a patient 

with a DNR and a POLST form is likely to receive more palliative 

care than those with just a DNR. 

Second, POLST is voluntary. The POLST—the National Task 

Force does not endorse or encourage programs where the completion of the POLST form is mandatory. 

Third, POLST can be easily modified or revoked. The Oregon registry shows that about 15 percent of all POLST forms submitted 

each month is a modification of a previous form. So as a patient’s 

disease progresses, their care goals can change and their treatment 

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preferences can change, so it is fundamental to the POLST Program that we allow for that. 

And, finally, this is the patient’s voice. Either the patient is the 

one having the conversation with the health care professional filling out the form or their surrogate is. So if the patient’s voice is 

not heard, the surrogate is the person to look to. By encouraging 

the advance care planning conversation between health care professionals and patients and by completing a POLST form when it is 

appropriate and desired, we are respecting patient autonomy. 

I appreciate the opportunity to be with you today. Thank you. 

[The prepared statement of Ms. Vandenbroucke follows:] 

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The CHAIRMAN. Thank you, Ms. Vandenbroucke. 

All right, Professor. You have heard the testimony of the previous witnesses. What do you think? How would you advise us? 

STATEMENT OF GLORIA RAMSEY, R.N., ASSOCIATE PROFESSOR, UNIFORMED SERVICES UNIVERSITY OF THE 

HEALTH SCIENCES 

Ms. RAMSEY. Great. Thank you. Thank you, Mr. Chairman, 

Ranking Member Collins, and distinguished members of the committee. I am really pleased to have the opportunity to speak with 

you this afternoon and to comment on the testimony that we have 

heard thus far, and also to have an opportunity to share with you 

some of the research that I have been engaged. 

I would like to begin with the comments or the testimony from 

Mr. Towey. At the onset, we heard about individuals who are poor, 

who are disabled, and who are powerless. It is the vulnerable populations that I would like to underscore that have not been a part 

of the discourse over the years. Although the PSDA was passed in 

1992, as Mr. Towey said, not all communities have been a part of 

the conversation. 

I would also like to comment with Ms. Warshaw and The Conversation Project and the idea that this is a grassroots effort, and 

believe me, change comes from the grassroots community, that the 

cultural norm needs to change, that these conversations need to 

happen where we work, where we live, and absolutely where we 

pray. My research largely embraces the faith community, and I will 

share that in a bit. 

Also, I would like to underscore that there is a deep desire to 

have the conversation, but individuals, even health care professionals, need assistance. They need help in how to begin the conversation, and that is equally important. And having it at kitchen 

tables sounds like a really great place, before the crisis, before the 

medical event when everyone then is uncertain about what is afoot. 

And, lastly, Ms. Vandenbroucke’s comments about the POLST 

and really introducing yet another opportunity to engage the patient and the patient’s voice. 

And it is all of these efforts that, I submit, are important for us 

as we renew the conversations that we have been charged with 

today, and we thank you for the opportunity to revisit some of 

what has occurred. 

And to that end, I would like to say that the views expressed are 

personal and do not reflect those of the Uniformed Services University of the Health Sciences or the Department of Defense. 

As I think about my own work, certainly starting in 1992 with 

the U.S. Supreme Court’s decision in Cruzan v. Director, Missouri 

Department of Health, and the Congress’ passage of the PSDA, this 

was a wonderful opportunity, if you will, to begin to inform patients of their rights to accept and refuse medical and surgical 

interventions. 

Today, we have heard statistics about the number of persons who 

are completing those, and I will certainly say to you, those who 

come from racial and ethnic diverse backgrounds as well as persons 

with disabilities, those numbers are far less. 

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And since passage of these laws and in recent years, recent studies report on the differences in decision making among racial and 

ethnic populations and patients with disabilities, and generally 

speaking, patients facing end-of-life care have the need to feel a 

sense of control, to have their pain appropriately assessed and 

managed, and as Senator Collins said, to be treated with respect 

and as a whole person. 

Barriers to quality end-of-life care for African Americans stem 

from mistrust of the health care system, inability to access health 

care, inability to identify with providers, and the lack of financial 

resources, especially as death approaches. In my own research, we 

found significant differences between whites’, non-Hispanic whites’, 

and blacks’ completion of advance directives and even their willingness to engage in health care planning conversations. Many feel 

that if they complete directives, that would be tantamount to an 

abandonment of care. 

So there is much to be done as we think about the health disparities that we see across our country, and yet the opportunity for 

us to really begin to elicit the patients’ perceptions, beliefs, and values. 

In conclusion, African Americans and other racially and ethnically diverse populations’ shared experiences, beliefs, and values 

influence their willingness to participate in advance care planning 

discussions, and advance care planning is an urgent public health 

concern and I thank you for renewing the conversation. 

[The prepared statement of Ms. Ramsey follows:] 

The CHAIRMAN. Excellent discussion. 

Senator Collins. 

Senator COLLINS. Thank you, Mr. Chairman. 

Mr. Towey, I think that most people believe that advance directives are used solely to give direction on the kind of care that a patient does not want to receive. But, in fact, they also, as your Five 

Wishes document shows, can be used to direct the kind of care that 

they do want to receive. How do we make sure that as health care 

providers discuss these issues with their patients, that they do so 

in a neutral way and not bias the decision one way or the other? 

I heard part of an NPR story this week that talked about how 

the way the question is asked can greatly influence the choice that 

is made, such as if you ask, do you want us to perform CPR if it 

means cracking open your ribs as we do so, you get a different response than if you put it in a different way. 

Mr. TOWEY. Well, Senator, I think you have identified one of the 

real defects with how Living Wills were promoted up until very recently. They were biased in favor of only communicating declination. I do not want this treatment. I do not want that treatment. 

Well, this has been remedied. As you said, Five Wishes now has 

let people choose to say, I do want in this circumstance of if I am 

seriously ill. 

I think beyond that, though, you get to the heart of the question, 

which is trust. There is such a mismatch. Many individuals have 

a crisis going on in their health before they even have these discussions. Then they are dealing with health care professionals that are 

speaking a language they do not understand. They are facing a 

health care system that has become increasingly more complicated. 

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As a result, a lot of distrust exists. People feel mismatched and inadequate to the conversation. 

I think the nice thing about The Conversation Project and what 

we have been doing in Five Wishes since 1996 is pushing it away 

from the emergency room and into the living room, the kitchen, 

and so forth. But there is this trust element, which is why a health 

care surrogate’s role is very important. And so often, if you do not 

have the conversation, then your surrogate is in as much of the 

dark as the health care provider. 

So I think that a good place to start, I think, would be for Congress to communicate to States in some way that they should not 

require individuals to fill out a form which says, I do not want care 

in—in other words, a form biased the way you describe. Currently, 

there are eight States that require you to fill out a State form. It 

is usually long. It is usually impossible to decipher by all but the 

most educated. And it is often of little or no use to health care providers. 

So a good start would say for the States to understand that these 

old vestiges of the past, where you have these antiquated Living 

Will statutes, give way to the more modern approach that lets people put their wishes in their own words. Let them have conversations, reduce it in writing, and communicate it to a health care surrogate, their health care professionals. That is the preferred route 

to go. 

Senator COLLINS. Thank you. 

Ms. Vandenbroucke, I was fascinated and touched by the story 

of Max that is in your testimony because it is so disturbing because 

he ended up getting care that was completely inconsistent with his 

wishes, and yet he had done everything possible to prevent that. 

You say in your testimony that EMTs have no choice but to do everything possible to save a life unless they have medical orders to 

the contrary, and I gather an advance directive is not considered 

to be a medical order, because you mentioned that his wife shows 

up with the advance directive and it does not do any good. 

I guess what I do not understand is how would the POLST system solve that? I mean, you are not going to be carrying the orders 

with you. 

Ms. VANDENBROUCKE. Well, you could. 

Senator COLLINS. But that is pretty unlikely—— 

Ms. VANDENBROUCKE. It is unlikely, I absolutely agree. So, you 

are right. To reiterate, the POLST is a medical order. It is not an 

advance directive, so advance directives are signed by individuals. 

A health care provider may never see it until there is a time of crisis and someone happens to be able to locate it at the time. But 

a POLST is a medical order signed by a health care professional. 

So in Max’s situation, if his wife had shown up, and this is our 

bright pink form, with it, then they would have said, okay, yes. We 

have got these medical orders. It is signed by a professional, a 

health care professional, and we are able to do what this form says 

to do or not to do. 

In Oregon, we do have a registry, so there are also certain situations where emergency personnel show up, and in this situation, if 

Max had completed a form but no one had it with them, which 

would be reasonable, they could say, he has got a POLST form, and 

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the emergency service people would call the registry and the registry would say, yes, this is the individual. Okay, he did not want 

CPR. He did not want this. Or, yes, he wants CPR. He wants that. 

And they would be able to act on those orders in the field at that 

time. 

Senator COLLINS. Thank you. 

The CHAIRMAN. Senator Warner. 

Senator WARNER. Thank you, Mr. Chairman. 

I want to follow up with Senator Collins. I think, is this not 

again one of the reasons why, though, we need some incentives so 

that that POLST order can translate across the State line? Could 

you speak to that, Ms. Vandenbroucke. 

Ms. VANDENBROUCKE. Yes. So, we do have some States that have 

put reciprocity for POLST orders into action, or into their State legislation. Some States just do it from a grassroots perspective. I 

know recently in Oregon, there was an Oregonian that had been 

vacationing in Wyoming and they happened to have their POLST 

form with them and they had an emergency, and the Wyoming 

folks ended up calling the Oregon registry, confirming that this 

was, in fact, a medical order, and they were able to treat the individual based on their POLST form at that moment. 

But it is certainly something that we are looking to, especially 

with the endorsed States. If you are a State that is endorsed by 

POLST, you know that the form has certain elements and certain 

things are not included on it, and so there is some standardization 

across those. So it is pretty easy from a reciprocity standpoint between those States, but as we are building in other States, it is 

something that we are working on. 

Senator WARNER. I would like to ask all of the witnesses, perhaps starting with Professor Ramsey, but just one of the things 

that we have been looking at in terms of—I think it is great, you 

have got to start the conversation, maybe in one setting, but then 

you have to then have that conversation with medical professionals 

that then gets translated into this medical order. 

The thing that we have kind of drilled down on, and starting 

with Professor Ramsey, but anybody could comment on, is that we 

found even within the kind of reimbursement that Medicare does 

right now, there is an availability to actually have a consultive 

team so that it is not just simply—it may be a nurse, it may be 

a social worker, it may be a doctor, so that there is some ability 

to help this kind of translation issue. Do you want to talk about 

that notion? 

Ms. RAMSEY. Yes, sir. That is important, because one of the 

things we found in our work is that individuals from the community would like to see individuals from the community, individuals 

who they perceive understand their preferences, their values, their 

social-economic status, their spiritual beliefs, and the like. 

African Americans do complete advance directives. We use the 

Five Wishes document in our research, and more than 80 percent 

of our persons have completed those. So to get a health care team 

who absolutely understands and appreciates the diversity and the 

inclusivity and also the cultural nuances and language considerations, as well, is important to really fully engage, and the Five 

Wishes document, again, was certainly one of those that was very 

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successful in our community and that we encourage our individuals 

to go to our local health care facilities with the document and the 

team is educated to know that it is a legally binding document and 

it is respected. 

Senator WARNER. I might just want to add, too, that one of the 

things we are looking at adding in our team is that ability to have 

that faith leader as part of that team, as well. 

Does anybody else want to comment on that? 

Mr. TOWEY. Yes, if I could just add to that, because I think it 

is not only just an issue of trust, where individuals want to believe 

that their wishes are going to be followed. There is a concern if the 

conversation is being held with individuals who have a financial 

stake in their decision. So if an individual is saying, I want the 

works until the very last breath, there is a financial dimension to 

that communication versus one that says, no, I do not want my 

sternum cracked. Please do not do this. 

And so as you move upstream, and you have, I think, very correctly said, Senator Warner, that you have got to go beyond just 

filling out a document and having a remote conversation. You actually have to have actionable plans, which is what I think POLST 

came into existence to remedy and has done effectively. 

Beyond that, you have got to have parties involved that are disinterested, that do not have a stake, that have no skin in that 

game financially. Otherwise, there is a feeling that people have 

that if they do not give the right answer, they may have trouble 

in their health care setting if they are feeling pressured to say, I 

do not want care. So that has been our experience. I am not sure 

how to remedy it, but again, I think the more communication is in 

place with the health care knowing exactly what that individual 

wants, I think it helps them further upstream when there is a crisis. 

Senator WARNER. But it is kind—and I want to hear from Ms. 

Warshaw—but it is a little bit of you have both examples. You have 

the example of someone feeling pressured maybe to kind of check 

too many boxes, but I will tell you, you also hear lots and lots from 

hospital systems where they will acknowledge where the absent 

relative who has not seen Grandma for months comes in feeling 

guilty and says, do it all. Disregard the wish of the patient. And 

trying to get that right is a real balance. 

Ms. Warshaw. 

Ms. WARSHAW. Thank you. I just wanted to comment, also, about 

the need to help our health professional staff feel comfortable having these conversations. What we have seen is they are humans, 

just like us, and find it challenging to have these conversations. 

And so we have been working with care managers, physicians, asking them to take off their professional hat, go through the starter 

kit, and experience what it is like and how challenging it is to have 

these conversations so that they then can lend that empathetic understanding and be ready to receive this discussion with their patients, because so few doctors feel comfortable starting the conversation, so—— 

Senator WARNER. Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Warren. 

Senator WARREN. Thank you, Mr. Chairman. 

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So, Ms. Warshaw, I appreciate your question, and you asked, 

have we had the conversation. We should lead by example. I just 

want to take this chance to say publicly, yes, I have had the conversation. I had it twice. 

My Aunt Bea started in about 40 years before she died—she died 

at 98—having the conversation. She was a shy, self-effacing 

woman, but she was determined that I would know what she wanted when the time came. And when we lost my mother very suddenly, my father after that insisted on having the conversation. 

Both of them said, ‘‘Betsy, we will be depending on you.’’ 

And I just want to say about the conversation, I had the confidence that I was doing what Aunt Bea wanted, what my Daddy 

wanted. It was their final gift to me, and that is what really 

mattered about the conversation. 

Ms. WARSHAW. I have had it with my two adult children, young 

adult, but adult children, and it was a hard conversation to have 

because nobody wants to have this. No one wants to think of their 

parents’ mortality. But, to me, it is a gift to them. It is 

unburdening making such difficult decisions. I never want them to 

have any regrets, and I had wonderful role models with my parents. Both of them have passed away, but I knew exactly what they 

wanted, and the last period, their end of their life, was a joy to be 

with both of them. 

Senator WARREN. Yes. So thank you. Thank you, and I encourage 

everyone to have the conversation. 

But what this discussion shows are the many benefits that we 

have from treating the whole patient, and the quality of life both 

for the patient and for the loved ones, and how we should strengthen our ways for getting more information here. And we have heard 

some great tools today. But the question I want to ask is how we 

can improve our Medicare program to make certain that seniors 

are being treated with dignity and respect, receiving the quality 

health care that is consistent with their individual values. You 

know, there is a lot of power in Medicare and I just want to start 

there, if we can. 

Dr. Ramsey, could you comment on that, please. 

Ms. RAMSEY. Great. Thank you. Again, in terms of my personal 

opinion, in terms of what the Federal Government has done, looking back in 1992 with the PSDA in terms of what were some of the 

opportunities that this particular legislation has provided, we have 

heard today that there is—Senator Warner is working on proposed 

legislation. And so I think that each of these that will have teeth, 

if you will, that actually expresses some guidance, would be enormously helpful for us. I think there was a lot of good that has come 

out of the PSDA. Was it—did we complete our total objectives? Not 

so much, but certainly, we are long on our way. So I think that in 

terms of using prior laws, examples such as that particular Federal 

law, will help us as you look forward with the current legislation. 

Senator WARREN. Thank you. 

Mr. Towey, would you like to add anything on that. 

Mr. TOWEY. Yes, Senator. It is the reimbursement system. So you 

have got to incent good practices, and so there should be review of 

how hospitals and care facilities and care providers are doing with 

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sions. Certainly, funding hospice in ways that gets them an earlier 

encounter, an earlier discussion with patients. They often are only 

brought in at the very end. There is a bias—it has been documented by the Dartmouth research that there is a bias toward hospitalization and curative care to the point where individuals, had 

they known what they were going to face the next 90 days, would 

not have tried radiation a third time. But, often, this is not communicated. It is simply a physician saying, we are going to try this. 

So these conversations are best, I think, also incented in medical 

schools, where you start training the next generation of care providers to understand that if you are really going to be in the caring 

professions, you cannot simply treat them as an object for your 

health care practice, that you have to help them understand, here 

is what is ahead if you choose this option versus this option. Often, 

the patient has no access to a physician, and so then the discussion 

is held by a social worker who has no idea who the individual is 

and it is broken down from the very beginning because their caseloads are too great and they are not funded any more by Medicare. 

So I think that a good way for Medicare to leverage its money 

is to incent good practices and also for us to be doing more with 

the medical schools to inform them about good pain management 

and earlier referral to hospice and better information for families 

and patients. 

Senator WARREN. Good. Well, I see my time is up, but I just 

want to say, thank you all. Thank you for the work that you do 

every day. And thank you again, Mr. Chairman, for reopening this 

conversation for all of us. 

The CHAIRMAN. Thank you, Senator. 

Senator Whitehouse. 

Senator WHITEHOUSE. Thank you, Chairman. Let me join the 

rest of the panel in thanking you and in thanking the Ranking 

Member for having yet another hearing on this issue and continuing to persist for results. This is so important. 

Ms. Vandenbroucke has Max. I had Martha, and it was the exact 

same situation. She was a very, very proud lady. She was determined that she was going to go out on her own terms, and she had 

her advance directives and everything else laid out, but she passed 

away in Virginia. And at the time, if you did not have a bracelet 

around your wrist that showed that you had signed up for this very 

specific program, the exact same thing happened. The EMTs came. 

She could have had her doctor, her lawyer, her priest, her family, 

her advance directive all right there saying no and the EMT would 

have said, well, tough bounce to all of you. We are doing what we 

are doing and we do not care. And they were legally obligated to 

do so. It is not because they are cold-hearted people. So fixing that, 

I think, is very important. 

And we are working on MOLST in Rhode Island. Maureen 

Glynn, who used to work for me in the Attorney General’s office, 

is leading that charge and is doing a terrific job and we are trying 

to get it through the Health Department right now. I want to 

thank particularly our Catholic Diocese, which has been extremely 

productive and helpful in the MOLST. Ms. Vandenbroucke says 

POLST for Physician. We call it MOLST for Medical, but it is the 

same idea. The Catholic Church has been very, very productive in 

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this discussion, has been very, very helpful, and in a State as 

Catholic as mine, it makes a big, big difference. 

And so keep doing what you are doing. If there is more that we 

can do to push this forward, give us advice, I am directly involved 

in that process in Rhode Island and I would love to be helpful in 

any way that your organization can give us advice. 

And thank you for reminding us, Ms. Warshaw, about the conversation. It is important to have. And I will reassure people that 

I have had it on both ends and I do not think it is that bad of a 

conversation. Kind of screwing up your guts to raise the subject is 

the hard part. Once you start talking about it, it tends to bring a 

cone of trust and of affection and of family reciprocal loyalty out 

in people. 

And so I do not think it is a conversation that we should be the 

least bit scared of or dread. In fact, every time I have talked to 

somebody about the conversation, when they are done with it, they 

feel way better than beforehand. It is not something where you 

walk away from it thinking, oh, that was a real ordeal. It is the 

exact opposite of that. It is a good thing for families to have that 

conversation. 

We are in an environment here where we can observe that most 

people who die are old people. Most old people are on Medicare. 

Medicare will have a lot to do with how these decisions get made 

at the end of life. And we are also in a political environment in 

which something as vile and pernicious as the death panel notion 

was able to actually get traction and frighten people that there 

might actually be such a thing. 

So what do each of you think would be the simplest, clearest, and 

most hobgoblin-proof improvements that we could make to Medicare, either by changing the law or by pushing the administration 

to make administrative changes, that would be a step forward in 

this direction, maybe not the final step forward, but a doable, clear, 

simple, non-controversial step forward? And quickly, because my 

time is running out. 

Ms. WARSHAW. So, since we are at the beginning of the food 

chain on this discussion and we are really interested in a whole 

cultural change, not just some—— 

Senator WHITEHOUSE. We cannot do cultural change that quickly, with a simple change. What can we do that is simple and clear? 

What can we push for? What is the first step? 

Ms. WARSHAW. Well, then I would suggest working with health 

systems to put the starter kit in every primary care physician’s office. 

Senator WHITEHOUSE. Okay. Ms. Vandenbroucke. 

Ms. VANDENBROUCKE. I would say—I know it is not necessarily 

non-controversial, but promoting that conversation. As Mr. Towey 

said earlier, the advance directives in some States, you need a 

Ph.D. to understand what they are saying and what they are asking for, and really, unless you have the conversation with a health 

care provider about what your options are, you are going to be believing that if you have CPR, or if you need CPR, it is going to be 

a couple of presses on your chest, you are going to be fine, because 

TV shows 75 percent of people that have CPR on TV walk away, 

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52 

when the reality is it is more like eight percent. And so people just 

do not even understand simple concepts, much less—— 

Senator WHITEHOUSE. We rewrote ours in Rhode Island because 

they are usually done when people are drafting their wills. 

Ms. VANDENBROUCKE. Yes. 

Senator WHITEHOUSE. So they are written by lawyers and for 

lawyers. Well, lawyers are not going to read them. Doctors are 

going to read them, and doctors speak a different language than 

lawyers, so—— 

Ms. VANDENBROUCKE. Exactly. 

Senator WHITEHOUSE [continuing]. We changed it from lawyerese 

to doctorese, and that helped at least a little bit. 

My time is expired, so let me just ask if you could reflect on my 

question as to what simple, clear steps would be that would be a 

good step forward, that are achievable in an environment in which 

the notion of a death panel might actually take footing, and just 

get back to us, because I do think that—— 

Senator WARNER. Share it with all of us. 

Senator WHITEHOUSE [continuing]. We very much want to work 

together on this issue. This is a truly bipartisan issue and a truly 

human and humane issue, and I appreciate the wonderful work 

that you are all doing to advance the cause. 

The CHAIRMAN. I always learn something from Senator Whitehouse, and today, I learned this beautiful turn of a phrase. Cone 

of trust. 

Senator WHITEHOUSE. Modeled on Maxwell Smart’s cone of silence. 

[Laughter.] 

The CHAIRMAN. Senator Ayotte. 

Senator AYOTTE. Thank you, Mr. Chairman. 

I appreciate all of the witnesses being here on such an important 

topic, and I know that there was a question asked to some extent 

when I was out of the room on this, but what I have heard from 

some of my concerns from constituents is that they have a situation 

where they either have two homes or they are traveling to visit a 

family member. Where they have an advance directive, they are 

worried that if—I have heard some, frankly, really bad stories 

about people who had advance directives, but one State did not respect the advance directive of another. And I know that some 

States do have some reciprocity, but what is it, in your view, that 

we could help make sure, not even—that States would respect the 

decisions and making sure that it is—the advance directive is 

drafted in such a way that there is some universal recognition? 

If you could help me—I know you may have already answered 

this, but this is an important issue that I think if we are going to 

respect people’s wishes in this regard, you know, we are a mobile 

society and there are too many of these stories and we never know 

when something is going to strike someone. 

Mr. TOWEY. Well, Senator, I think you have raised a very important issue, which is being able to carry your—nobody travels with 

their advance directive unless they are really on top of things. So 

Five Wishes is a national document used in 42 States. Eight 

States, of course, have language that requires you—and their statutes require you to use their form. But you still have the Patient 

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Self-Determination Act, which provides individuals this right as a 

Federal right. It has not been tested in court. Who wants to be a 

test case? 

But it is our view, as an advocate from the consumer standpoint, 

without any stake in the health care financing system, it is our 

view that they should be able to write it on a paper bag, their 

wishes, if they wanted to. It is not an effective way. It is not a good 

way. But it brings out the rights of individuals to communicate 

their wishes the way they would like. 

So I think what the Federal Government could do is renew its 

point that the Patient Self-Determination right supercedes State 

statutes that are limiting an individual’s exercise of their Patient 

Self-Determination right, at least as it applies to Medicare and 

Medicaid. You are paying for it. Why could we not see these States 

that have these mandatory forms recognize if they do not get with 

the better practices, they will lose their Federal funding? But until 

you do that, you will have this fractured system in place. 

Now, people with Five Wishes, fortunately, can travel to most 

States. But a lot of places, you run into horror stories, where individuals did not have their advance directive and a State will say, 

well, we do not honor what you have. You did not fill out the State 

form. 

Senator AYOTTE. No, I appreciate that. I do not know if anyone 

else has anything to add on that. 

One of the issues is we have talked a lot about, certainly, this 

issue with regard to end-of-life decisions when it comes to the elderly, which is, I think, very important to all of us. I am blessed 

to have a 97-year-old Grandfather and a 96-year-old Memay [phonetic] that are still with us, and, frankly, the sharpest people in 

the family when it comes to what is happening in the nation’s capital. 

But I think that one of the issues, when we think about it, this 

is not just an issue of impacting the elderly—we are here in the 

Aging Committee—but how do we start this conversation with people throughout their life, even younger people? You do not want to 

think about, obviously, when you are young, anything happening to 

you, but tragedies can happen at any moment in life and so this 

is sort of part of the life continuum. 

And so I just wanted to get your thoughts on—it is kind of like 

we are getting to the point where you are older and we are going 

to have this conversation, and it almost becomes a harder conversation because we are not incorporating that for some younger people 

in younger situations that can find themselves, obviously—none of 

us wants to think about this, but all of us want to make sure that 

our wishes are respected. 

Ms. WARSHAW. So, one of the ways that The Conversation Project 

is addressing this is recognizing that we need to start the discussion with people where they work, where they live, and where they 

pray. And so we have been working with employers to have this 

conversation with their employees, no matter what age they are. 

We have brought together in Boston 20 faith-based leaders, actually, two weeks after the Marathon bombing, and had an extraordinary working session with them. Together, we are beginning to 

develop a faith-based strategy for Boston that encompasses every 

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faith being represented and universally, not by age, bringing it to 

the faith-based communities. 

So, I think that you are right. As we learned in Boston, you get 

up in the morning and you do not know what is going to happen. 

And so we are trying to bring this concept, and that is why I say 

it is a cultural change, and we are hoping that we promote the day 

after Thanksgiving as ‘‘Talk Turkey’’ day with your family, when 

everybody is around, to have the conversation. 

So, if the government with Medicare would like to be a partner 

in this media campaign with us, we would love to have you as our 

partner. 

Senator AYOTTE. Thank you. I appreciate you all being here. 

The CHAIRMAN. Having been whipsawed on death panels and 

having gone through the experience of a Floridian, Terri Schiavo, 

I would think that younger people would want to go ahead and 

complete an advance directive. But, of course, we see the opposite 

in the statistics that you have given us. 

What do you think, is it human just ‘‘put off until a later day’’ 

kind of attitudes that is preventing us from having these discussions, and also of actually executing advance directives? Tell us 

what you think. 

Ms. VANDENBROUCKE. I heard about a book recently, and it was 

written by a young woman, and it was something like The Things 

That I Didn’t Know I Needed to Know as an Adult. And I think 

with advance directives, at least in my experience, being somewhat 

still young, people just do not know and they do not know the laws. 

I was in-house counsel at Oregon Health and Science University 

and one of the things that surprised a number of people is that the 

Oregon law, once you hit 18, there is no one that is legally designated to speak on your behalf. They expect you to fill out an advance directive to say, this is the person that can speak for you if 

you are incapacitated, and people just do not know that and they 

are not thinking about it. 

So, trying to get people aware of truly what can happen to them 

is, I think, something that can be an eye-opener, having a good 

story and just kind of communicating it that way. 

Mr. TOWEY. Senator, not only taking it to the workplace, and 

also, when you talk to young people—I am at Ave Maria University—the last thing they are thinking about is their mortality. So, 

one of the things that we have done with young people that has 

been helpful is to say, if you want to be a good son or daughter, 

have you talked to your parents about what they want so you can 

be there for them when they need you the most? And that has been 

effective to a point, because they do not mind getting in the face 

of their parents. 

And the real problem, when you look at the numbers in the 

Medicare and the Baby Boomer population, that group is going to 

live forever. Mick Jagger is going to be holding rock concerts until 

he has to have both hips replaced, and so they are, thankfully, joyfully forever young. And so trying to get the Baby Boomers engaged, I think, is even a greater, more important challenge for Congress, because they are the ones that are the consumers and so 

many of them do not have this. 

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And they have also—I put in my testimony, their profile healthwise is terrible. They are failing relative to previous generations on 

their health. So they are going to be needing more expensive care, 

more frequent care, and yet they have not even communicated 

their wishes. So we find that getting the kids to go to their parents 

now has been an effective strategy. 

But I think, lastly, is the faith community. They do not have any 

skin in the game, so they are able to speak with a voice that is unbiased, that is not tainted. There is no perception of a conflict of 

interest. Certainly, getting the leadership of our faith communities 

engaged in this discussion would be very helpful. 

The CHAIRMAN. And how do you take the information from a 

form such as Five Wishes and get this transferred over to Ms. 

Vandenbroucke’s form that actually has the doctor executing? 

Mr. TOWEY. Well, in States that have POLST, you certainly want 

to communicate to individuals, particularly if they are sick when 

they are filling this out, that they should know about POLST. We, 

of course, talk about DNR, but that is not enough. POLST is much 

more comprehensive. 

So what you would like to have, Senator, happen, is first, the advance care document filled out. That is your legal right. The discussion with your health care surrogate who knows exactly what you 

want, including issues related to POLST. And then, third, in your 

medical discussion with the physician, it is the physician, too, who 

should be bringing up the POLST discussion. Do you have an advance care directive? And have you had any discussion about 

POLST? So, hopefully, that is how the sequence would work. 

Ms. VANDENBROUCKE. And I would just add that the next step 

is then putting it into the medical record in a way that it is easily 

found at the time of an emergency, because if you have the forms 

and we cannot find them, then they do not have much value. 

The CHAIRMAN. And, of course, if we can get HHS to require this 

in the annual Medicare visit, that is just going to all the more add 

to the conversation. 

Does anybody know why HHS would not put that in? Is it 

money? 

Mr. TOWEY. I can speculate that I think they are fighting about 

getting anywhere near the death panel issue again. 

The CHAIRMAN. Ah. 

Mr. TOWEY. And so I think until—if ObamaCare is fully implemented, I think there is a fear that it will get derailed. The discussion will get diverted. So I think there may have been a reluctance 

on them to engage. That is just my speculation. Gloria or others 

may have a different point of view. 

Ms. VANDENBROUCKE. No, I agree with that. That is one of the 

grassroots efforts, I think, of most States that are trying to develop 

or enact the POLST Program, is reaching out to health care professional facilities who have EMRs, like Epic, and get them to modify 

it in such a way that you have a header like the one that is on the 

last page of my written testimony, where you can easily click on 

it. But they are having to do that more on a case-by-case basis. 

The CHAIRMAN. Ms. Warshaw. 

Ms. WARSHAW. Yes. I would just add that if we require our physicians to do this, we also need to educate them, because otherwise, 

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it will just be a checklist. There will be a check-off and there will 

not be a really robust conversation. And it is the subtleties of that 

robust conversation that influences whether your real wishes are 

implemented. 

Ms. RAMSEY. And I would add, in addition to the physicians, to 

the Advance Practice Nurses, the Doctors of Nursing Practice, the 

other health care professionals. 

I did want to comment in terms of the earlier comment about engagement of younger persons. One of the things that we are really 

seeing is that when you think about health disparities, the burden 

and incidence of disease among minority populations, whether it is 

cancer, cardiovascular disease, and the like, the burden of disease 

is taking its toll. And so the idea about why these conversations 

are particularly important is one that really has helped to upstream the conversation. 

So albeit the Karen Ann Quinlans and the Nancy Cruzans of the 

world were much younger, what we are finding with our work, because of the burden of disease and the lack of access to health care 

and the like, that we are seeing individuals who are living with 

chronic diseases and that we are forced—or at least it allows an opportunity to have a conversation, which is really providing access 

in a way that we have not seen in the past. 

The CHAIRMAN. Senator Collins. 

Senator COLLINS. Thank you, Mr. Chairman. 

As I have been listening about the debate on the discussion 

today, I thought of the fact that filling out a POLST order, for example, is very different at age 18, which was the point that Mr. 

Towey was making, than it is at my age or my parents’ age. And 

I do not know that we should be encouraging college students to 

fill out advance directives and POLST orders. I mean, I could easily 

fill this out now, but when I was at age 20, my answers would 

probably be totally different than they are now, and Mr. Towey, I 

think, was trying to get at that point when he talked about when 

this should be used. And, Ms. Vandenbroucke, you did say it was 

in most cases when someone would have less than a year to live 

or something like that. 

But talk to me about this issue and when we start, Mr. Towey, 

and go down. I mean, should this conversation that Ms. Warshaw 

has talked about, Professor Ramsey has talked about—is not this 

conversation a different outcome depending on how old you are? 

Mr. TOWEY. Yes, Senator. I do think that individuals that are 

older, it is a more immediate question and they have a different 

perspective, different values. And so one of the things that we see 

in advance care planning is individuals change their Living Wills 

all the time, or they go to their health care agent and they say, ‘‘I 

have changed my mind.’’ 

I just saw a friend that had a bad experience. I do not want that 

to happen to me. And so you will see changes, which is why I believe POLST has great promise, provided that it is used and kind 

of limited to the situations for which it was created, which is in the 

face of imminent health difficulty, serious illness, so that it is not 

seven years later that something you said after a car accident is 

being applied to you now that you have had a minor stroke. 

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So we urge there to be time limits on POLST for when it is written, and also the physician who is having that discussion with the 

patient, that there be documentation so you know who did it, so 

that there is a verification that this was done with the free, voluntary assent of the individual, because as Gloria has mentioned, 

many groups feel pressured, coerced, and inadequate to those conversations with a physician. 

Senator COLLINS. Thank you. 

Ms. Warshaw. 

Ms. WARSHAW. So, as I said, we are at the beginning of this discussion, and so what we encourage people to do is to speak with 

their loved ones about what their values are and what they want 

their end-of-life to feel like or look like, not specifically what tests 

or what type of health care they want. 

So it will change over time, and I think if you had asked Ellen 

what the perfect name for our organization would have been, she 

would have said ‘‘The Conversations Project,’’ but it is too difficult 

to say. So we recognize that this is just the beginning and it is a 

lifelong conversation. 

Senator COLLINS. Ms. Vandenbroucke. 

Ms. VANDENBROUCKE. Yes, so you are correct that the POLST 

form really is for the end-of-life and the focus is, earlier on in life, 

I think, completing that advance directive. And I think it is worth 

having the conversation early on because you just do not know 

what is going to happen. And as long as you have the conversation, 

even if the form is never filled out, you have a general sense of 

what your family member would have wanted. 

With respect to the POLST form, it is almost—I know that some 

States view it as a medical error if you fill it out too soon. So, one, 

this is a form that is initiated by a health care provider, not the 

individual. 

And, two, if a health care provider gave me a POLST form and 

said, ‘‘Fill it out,’’ or said, ‘‘I want to fill out this form for you,’’ that 

is completely inappropriate because this is putting a medical order 

into place that—well, one, if they are mandating it, that is a problem, but it is setting up for medical orders that would not be appropriate, because I am young, I am healthy, and I would want full 

treatments regardless, and that is what the law already provides 

for. So this is—it is something that would be reported to a board 

for a serious infraction if people are misusing this form. 

Senator COLLINS. Ms. Ramsey. 

Ms. RAMSEY. And I would only add that for the younger individuals, advance care planning is a process. It is not a one-shot deal. 

And so the idea about lots of your values, your attitudes, and your 

preference about other things are actually also addressed as we are 

having the advance care planning conversation. As my community 

member said, ‘‘If I were to step outside and get struck by a car, 

who would that person be that I would want to be there at my side 

to be the advocate for me, to be the navigator for me while I am 

hospitalized and receiving care?’’ 

So I think that, certainly, the end of life is along that continuum, 

but I think there are lots of advantages for engaging early, and 

that is what we have seen. 

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Senator COLLINS. Ms. Ramsey, just one final question, because 

you have just touched on an issue I wanted to raise, and that is 

I have heard so many stories and have seen friends where family 

members cannot agree and have very different views on what 

should be done and the patient is too ill to give direction and that 

conversation never took place. So you have made the very good 

point about making sure that there is someone who can make the 

decisions for you, but should that always be a family member necessarily? 

Ms. RAMSEY. Not necessarily, and I think that when I use the 

Five Wishes document in our work, one of the things that is expressly stated in the form, that it need not be a family member, 

because sometimes family members are not the best person. And 

so that is an important conversation, that it need not be your 

spouse or your oldest child, but rather it should be someone who 

is going to be able to articulate your preferences, is comfortable 

with that, and really is available to you, among some other criteria 

that would be helpful to consider. But, no, not necessarily that it 

has to be a family member. 

Senator COLLINS. Thank you, Mr. Chairman. Thank you. 

The CHAIRMAN. Senator Whitehouse, you have a request. 

Senator WHITEHOUSE. Mr. Chairman, I just wanted to ask unanimous consent that the opening statement I had intended to give if 

I had been here on time be included in the record as if I were. 

[The prepared statement of Senator Whitehouse follows:] 

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The CHAIRMAN. Indeed, without objection. 

Are you in your cone of silence? 

[Laughter.] 

Senator WHITEHOUSE. No, I am prepared to yield to Senator 

Blumenthal. 

The CHAIRMAN. Senator Blumenthal. 

Senator BLUMENTHAL. Thank you, Senator Whitehouse, and 

thank you, Mr. Chairman. 

I wonder—for the panel, I appreciate all of you being here on this 

very profoundly important topic. Connecticut, as you know, has 

taken a number of steps in this direction, and while I was Attorney 

General of the State, I supported those efforts, options for patients 

to provide instructions or to appoint someone to provide instructions to physicians, family members, and others about care choices. 

We thought this was especially important, and Connecticut helped 

to lead, when patients are unable to express themselves on these 

issues, and planning and preparation, and the term ‘‘conversation’’ 

was not quite as much in vogue as it has become today, so we 

thought there ought to be talks and discussions and family meetings and as much frank, good talk about this as possible. 

But there are also a lot of legal complexities surrounding these 

issues, and I have looked over some of the examples provided for 

options for end-of-life planning and advance directive and the Five 

Wishes form and so forth. I wonder, what options are available to 

enable people to better understand the governing law of their 

States, whether that is something that needs addressing. Obviously, people are not going to want to pay a lawyer, understandably, to do this for them, and most cannot afford a lawyer. So what 

options are there for furthering public understanding in the face of 

what they may think are legal complexities? 

Mr. TOWEY. Senator, it certainly has been the province of law 

firms often to provide a Living Will as part of their estate planning 

practice, and that has been somewhat effective, although they typically use the State form, so there is not really a useful document 

in play to begin with. 

But worse than that is the fact that most individuals who are 

poor, disabled, have no access to an attorney in the first place, and 

so we have been out there promoting the use of Five Wishes, make 

it—I think it is a dollar each for 25 or more—for faith communities, 

for financial planners, but also, you know, parish nurses, other individuals that are in the community itself, the aging centers, to be 

able to go upstream, reach individuals. 

And then our document is meant to be educative. It is meant to 

kind of help them understand what their rights are. You have 

passed, or Congress has passed the Patient Self-Determination Act. 

No one knows what is in it. It has been over 20 years. So that is 

why one of my recommendations was a renewed voice by Congress 

on the importance of advance care planning. 

I think when you deal with elderly in nursing homes, Senator, 

typically, when I go to a nursing home, I always ask at the front 

desk, how many people here have no visitors ever, and you get over 

half is the answer. So when you start talking about advance care 

planning for that population, you run into a whole different set of 

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circumstances. Then you layer on depression, which is not uncommon for individuals as they approach death. 

So as we educate families about their rights, one of the most important rights is to identify individuals who can be health care surrogates, maybe someone from their church, maybe the local community, that comes into a care setting like that and says, I am 

going to be helpful and befriend and visit those individuals. That 

would help them exercise their right. 

Senator BLUMENTHAL. Thank you. 

Any other responses? 

Ms. RAMSEY. One professional organization, the National Hospice 

and Palliative Care Organization, has a myriad of resources that 

are consumer-friendly in their initiative called Caring Conversations, and that has been one of the places that I have been able 

to, certainly, advise patients and families to also consult with. Not 

only is the directives from each of the States, whatever type of directive that State recognizes, whether it is a Living Will or a Durable Power of Attorney for Health Care, but they are both there, as 

well as instructions. 

And what they have also developed is a series of documents, 

pamphlets, that are really developed for consumers that is helpful 

for individuals to begin the conversation as well as to help them 

understand, well, what is life-sustaining treatment, you know, 

what does that look like, and the like. So that would be one of the 

examples that I would offer. 

Senator BLUMENTHAL. And I note that a number of the experts 

in this area have said that physicians are sometimes reluctant to 

address these issues, for whatever reason. Are you satisfied that 

physicians are, in effect, accepting the need to raise the issue 

proactively with their patients and persuade them to make some 

of these decisions and enlist others to do so? 

Ms. RAMSEY. I think in terms of medical schools across the country, nursing schools across the country, it is certainly something 

that we are getting better at. I think, as Ms. Warshaw said earlier, 

physicians and providers are waiting for patients and patients are 

waiting for providers, and that disconnect there really does give 

rise to a delay in time that is important to really begin the conversation. So in terms from an academic perspective, medical 

schools and nursing schools are really eliciting this content in 

terms of—into the content of the curriculum—excuse me—so that 

we can begin to help individuals role play in how to begin the conversation, how do you break bad news so that it is not as difficult 

as it is. 

And, lastly, it is another opportunity why the consumers, the lay 

individuals, need to be informed, so that they can be supportive in 

bringing the conversation up, as well. 

Ms. WARSHAW. I think we are experiencing a conspiracy of silence about discussing end-of-life issues, both from the medical 

community and from the public at large. And just like a generation 

ago when my parents would not use the word ‘‘cancer,’’ or we would 

not talk about gay rights, or there was no such term as ‘‘designated 

driver,’’ there has to be a cultural shift recognizing that this is a 

necessary adult responsibility of all of us to talk about what kind 

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of care we want at our end of our life, because death is not natural 

anymore with the enhanced technologies that we have. 

I would like to also add that the Institute for Health Care Improvement, where The Conversation is housed—which we are very 

appreciative of—is in the process of developing a curriculum in 

their open school program, which means it is online and free, all 

about The Conversation Project and how to begin having this conversation, and that is geared for interdisciplinary health care 

teams. 

Senator BLUMENTHAL. Well, I thank you very much. My time has 

expired, but I think the term ‘‘conspiracy of silence’’ is a very 

strong one, and I do not dispute it because I have no factual basis 

to dispute it. But I would have hoped that we would move beyond 

that, but I gather this panel feels that we have not and that is a 

very important call to action for all of us who are involved, which 

really means all of us, because we are all going to be there and all 

of us will have relatives, loved ones, friends, neighbors, who will be 

there, as well. 

So, I thank you very, very much, and thank you, Senator Nelson 

and Senator Collins, for having this hearing. 

The CHAIRMAN. Thank you, Senator. You are a very valuable 

member of this committee and you bring a great perspective as a 

former Attorney General. 

Ms. Ramsey, minorities—it was stated here that there are disparities in the minority communities about advance directives. Expand on that a little bit. 

Ms. RAMSEY. One of the things that we have found is that—I 

think it was stated at the onset that most times, we think of completion of advance directives as to refuse intervention. And for 

some, refusal is not what they are interested in. The idea is that, 

for many, there have not been access to health care, access to services, and that, finally, we do have access and now you want us to 

limit it or refuse it. Completing advance directives sometimes is 

perceived as being that you are going to be abandoned, that the 

care that you are getting, you are no longer going to get any of the 

care. And so that is part of the notion or the background about minorities and completion of advance directives. 

Similarly, about eight percent of minorities utilize hospice services. That is a very small number as compared to the majority at 

82 percent. That eight percent has been pretty static over—too 

long. And so the idea about individuals having access and knowledge about these services and to know that you can accept or you 

can refuse them, but at no time will you be abandoned and that 

your pain will be appropriately assessed and managed. 

The CHAIRMAN. You have been involved, Professor, in the Veterans Advisory Council on End-of-Life Care, and you know about 

the concerns about how advance care planning has been handled 

with our veterans. In your experience, tell us about your work with 

the Advisory Council and how these issues are raised with veterans. 

Ms. RAMSEY. Yes, sir. In terms of that particular Advisory Council, and recently, I completed an end-of-life nursing education consortium training for veterans, the idea is that many individuals 

who have served our country are not necessarily dying in places 

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like the VA or where individuals are trained in caring for veterans. 

And so the idea was that if individuals who served our country are 

in other acute care settings across the country, in hospices, that 

what are some of the things that would be important for providers 

to know as they transition, as they prepare for dying. 

And so it has been important for us to recognize that there are 

some particular considerations, if you will, for persons who have 

served and what we can do to make their dying experience meaningful and valuable, as we have done for others, but also appreciating that they have served our country. 

The CHAIRMAN. Thank you. 

Ms. Vandenbroucke, explain for the record the difference between the DNR form and the POLST form. 

Ms. VANDENBROUCKE. Thank you. The DNR form focuses just on 

resuscitation and the POLST form goes further and most States, it 

is a Section B, by saying, if you do not have an issue with resuscitation, what are the other things that you want at the end of life? 

So there are generally three options. You want comfort measures 

only, meaning that you want to allow natural death. You do not 

want to do anything to prolong your life. Limited additional interventions, which means that you would like things done. You might 

be in the ICU for a little bit, but you will get antibiotics and other 

treatments. Or full treatment, which is you want everything. 

And so this form goes a little bit further in asking those types 

of questions, whereas a DNR is generally just the one. 

The CHAIRMAN. Well, we have heard that sometimes patients 

with the traditional DNR, they get less treatment geared to the patient’s comfort, palliative care, but studies have shown that patients with a DNR order on a POLST form get more palliative care. 

Is that true? 

Ms. VANDENBROUCKE. Yes. There was a study that was done by 

Susan Hickman that was published in 2010 in the Journal of the 

American Geriatric Society that spoke to this, and she was essentially saying that POLST forms were highly associated with people 

making decisions about what they wanted at the end of life. And 

so when you had more orders that had greater specificity, you had 

a greater sense that this is what the patient wanted, whereas with 

DNR, generally, when people are seeing it, that that was just kind 

of treated as a way of just not providing as much care. They were 

interpreting it that the patient wanted less aggressive treatment 

done, when that may not have, in fact, been the case. And with a 

POLST, that was additional information about the level of care 

that the patient wanted in addition to the DNR. 

The CHAIRMAN. In the case where some physicians fill out the 

POLST form without involving the patient in the discussion of 

their goals and wishes, is there any evidence that any of you all 

know that this, in fact, has happened? It is not supposed to. 

Ms. VANDENBROUCKE. It is not supposed to, and I do not have 

any evidence of it. Most of the States do require signatures of the 

patient or the surrogate. Oregon happens to be one of the unique 

ones where we are just recommending that the signature occur. 

But the expectation from the program is that this conversation is 

occurring. The POLST, as I said at the beginning, is not just a 

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form, it is a conversation, and the form is only as good as that conversation. 

The CHAIRMAN. Thank you very much. 

Professor Ramsey, I want to go back to the previous question. 

There was the suggestion in the VA that they were creating death 

panels. What do you know about that? 

Ms. RAMSEY. I do not, sir. 

The CHAIRMAN. Okay. I want you to ask about that the next time 

you are in the Council. 

Mr. Towey. 

Mr. TOWEY. Mr. Chairman, as you know, back in 2009, when the 

VA floated a document called ‘‘My Life, My Choices,’’ there was 

controversy around it. The concern for the poor and the handicapped and others that feel mismatched to begin with is when a 

huge provider of services is also very anxiously trying to discuss it, 

it can be—to discuss the issue, advance care planning, they could 

have a serious conflict of interest, because they also are under tremendous budgetary pressure to save money. 

That does not mean we should be funding every last bit of care 

every individual wants, and, in fact, most people do not even want 

that care at the end of life. They do not. If you ask people, do they 

want their last three days spent that way, they would say no. And 

so part of advance care planning is for them to say, I want it in 

this situation, but I do not want it in this situation, the same as 

POLST would allow. 

The problem when the health care community directly, such as 

VA, or secondary, such as a reimbursement scheme of Medicare or 

Medicaid, when they are leading the discussion, people are suspicious. They are frightened that what you are really trying to do 

is cut costs, and they are saying what is really better for you is to 

go straight to palliative care when, in fact, your treatment plan in 

front of you, curative care, could lead to a recovery. So that is why 

I think the VA has to proceed very cautiously when it seeks to promote end-of-life discussions. 

The CHAIRMAN. And, of course, the subject of this entire discussion, advance directives, could alleviate any of these questions 

about whether or not there are going to be death panels. And, of 

course, if it is appropriately authenticated and signed with an 

order, with, as you said, Ms. Vandenbroucke, the patient’s signature on there, as well, then I think it starts to alleviate a lot of 

the concern. 

Senator Collins. 

Senator COLLINS. Thank you, Mr. Chairman. 

I do not have any more questions for this panel, but I want to 

thank each member for your very informed, insightful, and intelligent discussion of this issue. Both the Chairman and I are truly 

committed on this issue, and I think it is really sad when this important discussion degenerates into slogans and demagoguery, such 

as death panels, when it is so important to each and every one of 

us. And I commend all of you for the work that you have done, your 

research, the Five Wishes Program, the other initiatives to elevate 

the discussion, which it deserves. 

So, thank you very much, and Mr. Chairman, thank you for your 

longstanding interest and work in this issue. 

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The CHAIRMAN. And with those very kind words, we both extend 

a hearty thank you to all of you for an excellent discussion. 

The meeting is adjourned. 

[Whereupon, at 3:53 p.m., the committee was adjourned.] 

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