title: Completion of advance directives by older health maintenance organization members: the role of attitudes and beliefs regarding life-sustaining treatment.
abstract: OBJECTIVE
  This study examined whether older health maintenance organization (HMO) members' attitudes and beliefs regarding life-sustaining treatment were associated with their completion of advance directives (ADs).
  
  
  METHODS
  A mailed survey of 1,247 subjects, aged 75 and older, participating in a randomized trial comparing two educational interventions designed to increase AD completion: mailed written materials versus written materials plus a videotape. AD completion was documented by medical record review.
  
  
  METHODS
  The initial trial took place in October 1994 at a large group-model HMO in the Denver metropolitan area. The survey was mailed to participants 3 months after the trial.
  
  
  METHODS
  All HMO members aged 75 and older who received medical care at one of the medical offices (n = 1247) were mailed the survey. Participants were the 735 members who returned the survey.
  
  
  METHODS
  AD completers were compared with noncompleters on survey items pertaining to attitudes and beliefs regarding life-sustaining treatment.
  
  
  RESULTS
  Of survey respondents, AD completers (n = 313) differed from noncompleters (n = 422) in their agreement with the following attitudinal/belief statements: (1) Putting my wishes for life-sustaining treatment in writing is too binding (completers = 12, noncompleters = 35); (2) I prefer that my family decide what kind of medical care is best for me if I should become unable to communicate my wishes (completers = 69, noncompleters = 88); and (3) My physician clearly understands my wishes for life-sustaining treatment (completers = 76, noncompleters = 43; all values, P< .0001).
  
  
  CONCLUSIONS
  Completers were more likely to believe that their physicians understood their wishes and less likely to think that ADs are too binding. More noncompleters wanted their family to decide, even though an AD would increase their families' ability to do so. AD completion rates might increase if they were characterized as a way to preserve flexibility in a complex medical system, help families reach amicable decisions on behalf of their loved ones, and increase patients' confidence that their physician understands their wishes for life-sustaining treatment.
authors.affiliation: Clinical Research Unit, Kaiser Permanente, Colorado Region, Denver, USA. arne.beck@kp.org
authors.forename: Arne
authors.initials: A
authors.lastname: Beck
authors.forename: Jonathan
authors.initials: J
authors.lastname: Brown
authors.forename: Myde
authors.initials: M
authors.lastname: Boles
authors.forename: Paul
authors.initials: P
authors.lastname: Barrett
mesh_terms: D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D003120:Colorado; D005260:Female; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006279:Health Maintenance Organizations; D006801:Humans; D008020:Life Support Care; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis