There is a large gap between the care seriously ill patients want and the care they receive. Advance directives (ADs) offer an opportunity for patients to express specific end-of-life preferences to avoid unwanted care. As promising as ADs may be for improving the quality of care near the end of life, rates of AD completion remain low and previous efforts to encourage their completion have had limited success. Principles of behavioral economics, such as the effects of defaults and other framing effects, may offer a novel approach to bridge the gap in end-of-life care. This study tested whether the framing effect of expanding choice sets could increase the completion of and specification of choices within ADs among adult patients with end-stage renal disease (ESRD), as they historically have low uptake of ADs despite a median survival shorter than many cancers. Patients were randomized to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. The expanded options differed by the number of choices offered to designate life-sustaining preferences. Patients were recruited from 15 dialysis centers in the Philadelphia region between July 2014 and July 2015. We sought to understand 1) if expanding the choices for completing different types of ADs would increase completion of any AD, and 2) among patients who complete ADs, if expanded choice sets within ADs would decrease the proportion of patients who do not specify preferences for life-sustaining therapies.
Otto Haas Charitable Trust, Roybal Center on Behavioral Economics and Health, National Institute on Aging, National Institute of Diabetes and Digestive and Kidney Diseases, National Heart, Lung, and Blood Institute
We did not find differences in completion rates between the standard versus expanded choice set groups (13.1% in the standard group vs. 12.2% in the expanded group), but an expanded choice set increased the proportion of seriously ill patients who said they wanted to complete an advance directive (71.9% in standard vs. 85.3% in expanded). Consistent with previous literature, patients who wanted to complete an advance directive were more likely to do so if they had higher quality-of-life scores, had prior end-of-life discussions, or were white. Findings from this study suggest that simply focusing on initial engagement by expanding choice options may not be enough to facilitate advance directive completion among patients. Many patients face downstream barriers to completing advance directives, including cognitive biases (e.g., overoptimism), lack of certainty surrounding diagnoses, legal hurdles such as requirements for signatures or notarization, and additional emotional and time-related stressors associated with having to think through end-of-life decisions and documents. These individual barriers should be taken into account in future interventions aimed at increasing advance directive completion, and interventions should be sensitive to providing options for modality of completion (e.g. in person, by mail, or online).