Advance care planning.
BACKGROUND
Advance directives (AD) with specific treatment preferences can be difficult to apply in actual clinical situations. As an alternative, advance directives that outline patient goals and values have been advocated.


OBJECTIVE
To compare patient reactions to values-based and treatment-based advance directive forms.


METHODS
Two academic general medicine outpatient clinics in Pittsburgh, Pa.


METHODS
Outpatients age 55 or older who did not have an AD and were not demented were randomly assigned to complete either Emanuel's Medical Directive (EMD) or Pearlman's values history (PVH) form.


METHODS
Length of time to complete and number of questions asked about the AD forms; proportions of patients discussing the AD with family, designating a surrogate, returning the AD by mail, and desiring to have the AD in the medical record; patient ratings of AD by telephone interview; physician report of patient-initiated AD discussions.


RESULTS
Of the 275 patients approached, 143 refused, 69 already had an AD, 63 patients were enrolled, and 25 in each group completed the telephone interview. A majority of individuals in both groups had conversations with others about the AD (60% EMD, 56% PVH; P = .77). All PVH forms designated a surrogate, whereas 79% of EMD forms did so (P = .02). One patient in each group initiated a conversation with his or her physician about AD following study completion. Both forms were thought to be a good first step in planning care at the end of life (92% EMD vs 84% PVH totally or mostly agree; P = .06). Patients completing the EMD thought it would give them control over the way their doctor cared for them at the end of their lives more than did the PVH group (84% EMD vs 48% PVH totally or mostly agree; P = .02). More patients completing the EMD form worried that it would be difficult to change answers on the form if they later changed their minds (20% EMD vs 4% PVH totally or mostly agree; P = .02).


CONCLUSIONS
Both the values-based and treatment-based AD forms were rated favorably overall. Patients thought the treatment-based directive would give them more control over their care. Patients completing the values history form were more likely to designate a surrogate. Patients are likely to discuss both types of AD with family, but neither form alone is likely to lead to AD conversations with physicians.
Kolarik
Russ C
RC
Division of General Internal Medicine and General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa, USA. kolarikrc@msx.upmc.edu
Arnold
Robert M
RM
Fischer
Gary S
GS
Hanusa
Barbara H
BH
D016223:Advance Directives; D000368:Aged; D001294:Attitude to Health; D003657:Decision Making; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations