A Randomized Trial of Expanding Choice Sets to...
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