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A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion.

ABSTRACT: Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge.This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients.Outpatients ( N = 316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive either the option to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. Patients in both groups could decline to complete an advance directive or take their selected version home. The primary outcome was a returned, completed advance directive. Secondary outcomes included whether patients wanted to complete an advance directive, decision satisfaction, quality of life at 3 months, and patient factors associated with advance directive completion.Although offering more advance directive options was not significantly associated with increased rates of completion (13.1% in the standard group v. 12.2% in the expanded group, P = 0.80), it did significantly increase the proportion of patients who wanted to complete an advance directive and took one home (71.9% in standard v. 85.3% in expanded, P = 0.004). There was no difference in satisfaction ( P = 0.65) or change in quality of life between groups ( P = 0.63). A higher baseline quality of life was independently associated with advance directive completion ( P = 0.006).These results suggest that although an expanded choice set may initially nudge patients toward completing advance directives without restricting choice, increasing actual completion requires additional interventions that overcome downstream barriers.

SUBMITTER: Courtright KR

PROVIDER: S-EPMC5303189 | biostudies-literature | 2017 Jul

REPOSITORIES: biostudies-literature

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A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion.

Courtright Katherine R KR Madden Vanessa V Gabler Nicole B NB Cooney Elizabeth E Kim Jennifer J Herbst Nicole N Burgoon Lauren L Whealdon Jennifer J Dember Laura M LM Halpern Scott D SD

Medical decision making : an international journal of the Society for Medical Decision Making 20160810 5

<h4>Background</h4>Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge.<h4>Objective</h4>This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients.<h4>Methodology</h4>Outpatients ( N = 316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive ...[more]

PMID: 27510741

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Project description:BackgroundAdvance care planning (ACP) is a process involving conversations between patients, loved ones, and healthcare providers that consider patient preferences for the types of medical therapies received at the end of life. Underserved populations, including Black, Hispanic, rural, and low-income communities are less likely to engage in ACP than other communities, a health inequity that results in lower-quality care and reduced hospice utilization. The purpose of this trial is to compare efficacy of two interventions intended to motivate ACP (particularly advance directive completion) for those living in underserved communities.MethodsThis 3-armed cluster, randomized controlled mixed methods design is being conducted in 75 community venues in underserved communities across the USA. The goal of the trial is to compare the efficacy of two interventions at motivating ACP. Arm 1 uses an end-of-life conversation game (Hello); Arm 2 uses a nationally utilized workshop format for ACP conversations (The Conversation Project); and Arm 3 uses an attention control game (TableTopics). Events are held in partnership with 75 local community-based host organizations and will involve 1500 participants (n=20 per event). The primary outcome is completion of a visually verified advance directive at 6 months post-event. Primary analyses compare efficacy of each intervention to each other and the control arm. Secondary mixed methods outcomes include (a) other ACP behaviors and engagement; (b) communication quality; (c) impact of sociocultural environment on ACP (via qualitative interviews); and (d) implementation and sustainability. Subgroup analyses examine outcomes for Black, Hispanic, and rural groups in particular.DiscussionThis trial will add to the evidence base behind various conversational ACP interventions, examine potential mechanisms of action for such interventions, and provide qualitative data to better understand the sociocultural environment of how community-based ACP interventions are experienced by underserved populations. Results will also provide important data for future researchers to learn whether visual verification of advance directives is necessary or whether reliance on self-reported outcomes is of comparable value. Data from this study will inform ways to effectively motivate underserved communities to participate in advance care planning.Trial registrationClinicalTrials.gov NCT04612738. Registered on October 12, 2020. All information from the WHO Trial Registration Data Set can be found within the protocol.

Project description:ObjectiveCompletion of an advance directive (AD) document is one component of advanced care planning. We evaluated a brief intervention to enhance AD completion and assess whether the intervention effect varied according to health literacy.MethodsA randomized controlled study was conducted in 2 internal medicine clinics. Participants were over 50, without documented AD, no diagnosis of dementia, and spoke English. Participants were screened for health literacy utilizing REALM-SF. Participants were randomized in a 1:1 ratio to the intervention, a 15-minute scripted introduction (grade 7 reading level) to our institution's AD forms (grade 11 reading level) or to the control, in which subjects were handed blank AD forms without explanation. Both groups received reminder calls at 1, 3, and 5 months. The primary outcome was AD completion at 6 months.ResultsFive hundred twenty-nine subjects were enrolled; half were of limited and half were of adequate health literacy. The AD completion rate was 21.7% and was similar in the intervention vs. the control group (22.4% vs 22.2%, P = .94).More participants with adequate health literacy completed an AD than those with limited health literacy (28.4% vs 16.2%, P = .0008), although the effect of the intervention was no different within adequate or limited literacy groups.ConclusionA brief intervention had no impact on AD completion for subjects of adequate or limited health literacy.Practice implicationsOur intervention was designed for easy implementation and to be accessible to patients of adequate or limited health literacy. This intervention was not more likely than the control (handing patients an AD form) to improve AD completion for patients of either limited or adequate health literacy. Future efforts and research to improve AD completion rates should focus on interventions that include: multiple inperson contacts with patients, contact with a trusted physician, documents at 5th grade reading level, and graphic/video decision aids.Trial registration numberNCT02702284, Protocol ID IRB201500776.

Project description:Advance care planning is relevant for homeless individuals because they experience high rates of morbidity and mortality. The impact of advance directive interventions on hospital care of homeless individuals has not been studied. The objective of this study was to determine if homeless individuals who complete an advance directive through a shelter-based intervention are more likely to have information from their advance directive documented and used during subsequent hospitalizations. The advance directive included preferences for life-sustaining treatments, resuscitation, and substitute decision maker(s). A total of 205 homeless men from a homeless shelter for men in Toronto, Canada, were enrolled in the study and offered an opportunity to complete an advance directive with the guidance of a trained counselor from April to June 2013. One hundred and three participants chose to complete an advance directive, and 102 participants chose to not complete an advance directive. Participants were provided copies of their advance directives. In addition, advance directives were electronically stored, and hospitals within a 1.0-mile radius of the shelter were provided access to the database. A prospective cohort study was performed using chart reviews to ascertain the documentation, availability, and use of advance directives, end-of-life care preferences, and medical treatments during hospitalizations over a 1-year follow-up period (April 2013 to June 2014) after the shelter-based advance directive intervention. Chart reviewers were blinded as to whether participants had completed an advance directive. The primary outcome was documentation or use of an advance directive during any hospitalization. The secondary outcome was documentation of end-of-life care preferences, without reference to an advance directive, during any hospitalization. After unblinding, charts were studied to determine whether advance directives were available, hospital care was consistent with patient preferences as documented in advance directives, and hospital resource utilization during admission. During the 1-year follow-up period, 38 participants who completed an advance directive and 37 participants who did not complete an advance directive had at least one hospitalization (36.9 vs. 36.2 %, p = 0.93). Participants who completed an advance directive were significantly more likely to have documentation or use of an advance directive in hospital, compared to participants who did not complete an advance directive (9.7 vs. 2.9 %, p = 0.047). Without reference to an advance directive, documentation of end-of-life care preferences occurred in 30.1 vs. 30.4 % of participants, respectively (p = 0.96), most often due to documentation of code status. There were no significant differences in resource utilization between admitted patients who completed and did not complete an advance directive. In conclusion, homeless men who complete an advance directive through a shelter-based intervention are more likely to have their detailed care preferences documented or used during subsequent hospitalizations.

Project description:Importance:Documentation rates of patients' medical wishes are often low. It is unknown whether easy-to-use, patient-facing advance care planning (ACP) interventions can overcome barriers to planning in busy primary care settings. Objective:To compare the efficacy of an interactive, patient-centered ACP website (PREPARE) with an easy-to-read advance directive (AD) to increase planning documentation. Design, Setting, and Participants:This was a comparative effectiveness randomized clinical trial from April 2013 to July 2016 conducted at multiple primary care clinics at the San Francisco VA Medical Center. Inclusion criteria were age of a least 60 years; at least 2 chronic and/or serious conditions; and 2 or more primary care visits; and 2 or more additional clinic, hospital, or emergency room visits in the last year. Interventions:Participants were randomized to review PREPARE plus an easy-to-read AD or the AD alone. There were no clinician and/or system-level interventions or education. Research staff were blinded for all follow-up measurements. Main Outcomes and Measures:The primary outcome was new ACP documentation (ie, legal forms and/or discussions) at 9 months. Secondary outcomes included patient-reported ACP engagement at 1 week, 3 months, and 6 months using validated surveys of behavior change process measures (ie, 5-point knowledge, self-efficacy, readiness scales) and action measures (eg, surrogate designation, using a 0-25 scale). We used intention-to-treat, mixed-effects logistic and linear regression, controlling for time, health literacy, race/ethnicity, baseline ACP, and clustering by physician. Results:The mean (SD) age of 414 participants was 71 (8) years, 38 (9%) were women, 83 (20%) had limited literacy, and 179 (43%) were nonwhite. No participant characteristic differed significantly among study arms at baseline. Retention at 6 months was 90%. Advance care planning documentation 6 months after enrollment was higher in the PREPARE arm vs the AD-alone arm (adjusted 35% vs 25%; odds ratio, 1.61 [95% CI, 1.03-2.51]; P?=?.04). PREPARE also resulted in higher self-reported ACP engagement at each follow-up, including higher process and action scores; P <.001 at each follow-up). Conclusions and Relevance:Easy-to-use, patient-facing ACP tools, without clinician- and/or system-level interventions, can increase planning documentation 25% to 35%. Combining the PREPARE website with an easy-to-read AD resulted in higher planning documentation than the AD alone, suggesting that PREPARE may increase planning documentation with minimal health care system resources. Trial Registration:clinicaltrials.gov Identifier: NCT01550731.

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A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion.

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A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion.

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