Dr. Yoshiyuki Kizawa faces the same dilemma as physicians in other countries when talking to patients and families about end-of-life decisions.

The Japanese physician said he finds a health care system with no end-of-life planning or coordinated program. Japanese families make decisions in their loved one's lives, he said, but physicians still control end-of-life issues.

Kizawa is trying to change that with the help of the advance directive program developed in La Crosse that has been widely recognized. He attended two days of advance care planning training this week at Gundersen Lutheran with health care providers from eight states and three countries.

He first wants to use the model at his university hospital, he said, but hopes it will spread throughout Japan.

"I like this model," Kizawa said. "It will help patients and physicians."

Gundersen Lutheran and Franciscan Skemp in 1991 spearheaded the La Crosse Medical Centers Task Force on Advance Directives that developed Respecting Choices, a program to encourage people to have advance directives.

Since 2002, Gundersen Lutheran has developed Respecting Choices into a non-profit educational organization to train health care providers to set up programs. More than 50 U.S. communities, including the Twin Cities and Chicago areas, have adopted the program.

The most successful initiative has been in Australia, which set up a national program and created interest in other countries, said Linda Briggs, a registered nurse and associate director for Respecting Choices.

Gundersen Lutheran officials now are working to establish programs and research projects in Canada, Singapore, Germany and Spain, Briggs said. Hong Kong is next on the list.

"We help people get started, and then the program evolves and grows," Briggs said.

She said she has experienced more barriers to end-of-life discussions in the United States than some other countries.

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