In 1999, Gundersen Lutheran Medical Foundation, Inc. made a commitment to support development of a national Respecting Choices program to provide consultation and education to other communities, organizations, and countries interested in replicating the Respecting Choices model. This program has spread internationally, producing several stories of successful replication.

The Respecting Patient Choices program (RespectingPatient in Australia is modeled after the La Crosse program. Respecting Choices faculty provided extensive consultation and education to help the Australian leaders customize the key elements described above to address the diverse needs of this country. Through a commitment to quality improvement and research, the Respecting Patient Choices program has documented success and has become a national model for implementation in Australia. This program has established standards of practice for documentation of advance care plans, common education and engagement materials, training of facilitators (called ACP counselors), and secured funding for ongoing dissemination, media resources, and research. In 2012, they published the results of a randomized controlled trial of the Respecting Choices–based ACP facilitation intervention in medical inpatients aged 80 years and older. Patients who received the intervention were significantly more likely to have their wishes known and followed than those in the control group (Detering et al., 2010). Patients and families in the intervention group were also more satisfied with their overall hospital experience than were those in the control group. Additionally, family members of
patients who died in the intervention group experienced significantly less stress, anxiety, and depression than control group family members. These outstanding research outcomes are reflective of a well-designed system that was monitored and improved over time.

Implementation of the Respecting Choices program is also occurring in the metropolitan communities of Minneapolis/St. Paul in Minnesota. Under the leadership of the Twin Cities Metro Society, 40 members of the Twin Cities health care communities agreed to adopt the Respecting Choices model and collaborate in developing consistent materials (e.g., common documents and education materials), facilitator training, and community engagement (Wilson & Schettle, 2012). These health care leaders agreed not to compete in the area of ACP, collaborate during implementation, and invest in resources to continue dissemination. Among the many outcomes this initiative has achieved is the development of a community engagement campaign in partnership with Twin Cities Public Television that includes listening sessions and an interactive website ( While complete geographic implantation will take several years, leaders have established credibility and expertise to assist other communities across Minnesota in adopting the principles of what the Twin Cities group is calling Honoring Choices Minnesota.

The Respecting Choices Next Steps ACP stage of planning has been replicated with successful outcomes in such health care systems as Allina Hospitals and Clinics, Minneapolis, Minnesota, and for adolescents with HIV/AIDS. Allina Hospitals and Clinics have adopted and implemented a comprehensive ACP program that includes all stages of planning. In particular, the leaders of this initiative have demonstrated the positive outcomes of the Next Steps ACP intervention for heart failure patients, reporting a high rate of completion of a disease-specific planning document to guide future decisions resulting from advanced illness. Heart failure patients who died during the study period were more likely than nonparticipants to use hospice services (Schellinger, Sidebottom, & Briggs, 2011). This study demonstrated important lessons in implementing the Next Steps intervention into clinical practice and gaining support for further dissemination.

The Respecting Choices Next Steps intervention has been successfully replicated in an adolescent population with HIV/AIDS. In a randomized, controlled pilot study, researchers from Children's National Medical Center in Washington, DC reported on the feasibility and acceptability of the family-centered intervention with mostly black, medically stable adolescents with HIV/AIDS and their parent/guardian (Lyon et al., 2009). Compared with the control group, the intervention group demonstrated a significant increase in parent/guardian understanding of their loved one's preferences. Intervention adolescents reported feeling better informed and supported than did their counterparts in the control group. The further
investigation of these pilot results is being studied in a randomized, controlled trial funded by the National Institutes of Health.

At Gundersen Health System, the Next Steps ACP intervention has been integrated into a novel program for patients with advanced illness called Advanced Disease Coordination (ADC) (Klemond, 2012). In an effort to more effectively identify and coordinate the complex needs of patients with advanced illness, the ADC program links the unique and related services of ACP, care coordination, and palliative care. The goals of this program are to establish and maintain relationships with patients and families over their final months to years of life, providing timely and appropriate access to needed resources.

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