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Active choice intervention increases advance directive completion: A randomized trial

Medical Decision Making February 20, 2018

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BACKGROUND: Many people recognize the potential benefits of advance directives (ADs), yet few actually complete them. It is unknown whether an active choice intervention influences AD completion. 

METHODS: New employees were randomized to an active choice intervention (n = 642) or usual care (n = 637). The active choice intervention asked employees to complete an AD, confirm prior AD completion, or fill out a declination form. In usual care, participants could complete an AD, confirm prior completion, or skip the task. We used multivariable logistic regression to assess the relationship between the intervention arm and both AD completion online and the return of a signed AD by mail, as well as assess interactions between intervention group and age, gender, race, and clinical degree status. 

RESULTS: Participants assigned to the active choice intervention more commonly completed ADs online (35.1% v. 20.4%, P < 0.001) (odds ratio [OR] = 2.10; 95% confidence interval [CI] = 1.63–2.71; number needed to treat = 6.8) and returned signed ADs by mail (7.8% v. 3.9%, P = 0.003; number needed to treat = 25.6). The effect of the intervention was significantly greater among men (OR = 4.13; 95% CI = 2.32–7.35) than among women (OR = 1.74; 95% CI = 1.30–2.32) (interaction P value < 0.001). Responses to all eight choices made in the ADs were similar between groups (all P > 0.10). 

LIMITATIONS: A young and healthy participant may not benefit from AD completion as an older or seriously ill patient would. 

CONCLUSIONS: The active choice intervention significantly increased the proportion of participants completing an AD without changing the choices in ADs. This relationship was especially strong among men and may be a useful method to increase AD completion rates without altering choices.


Otto Haas Charitable Trust
University of Pennsylvania Health System