title: An advance directive redesigned to meet the literacy level of most adults: a randomized trial.
abstract: OBJECTIVE
  To determine whether an advance directive redesigned to meet most adults' literacy needs (fifth grade reading level with graphics) was more useful for advance care planning than a standard form (>12th grade level).
  
  
  METHODS
  We enrolled 205 English and Spanish-speaking patients, aged >/=50 years from an urban, general medicine clinic. We randomized participants to review either form. Main outcomes included acceptability and usefulness in advance care planning. Participants then reviewed the alternate form; we assessed form preference and six-month completion rates.
  
  
  RESULTS
  Forty percent of enrolled participants had limited literacy. Compared to the standard form, the redesigned form was rated higher for acceptability and usefulness in care planning, P</=0.03, particularly for limited literacy participants (P for interaction </=0.07). The redesigned form was preferred by 73% of participants. More participants randomized to the redesigned form completed an advance directive at six months (19% vs. 8%, P=0.03); of these, 95% completed the redesigned form.
  
  
  CONCLUSIONS
  The redesigned advance directive was rated more acceptable and useful for advance care planning and was preferred over a standard form. It also resulted in higher six-month completion rates.
  
  
  CONCLUSIONS
  An advance directive redesigned to meet most adults' literacy needs may better enable patients to engage in advance care planning.
authors.affiliation: Division of Geriatrics, University of California San Francisco and the San Francisco Veterans Affairs Medical Center, CA 94121, USA, United States. rsucsf@yahoo.com
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Sudore
authors.forename: C Seth
authors.initials: CS
authors.lastname: Landefeld
authors.forename: Deborah E
authors.initials: DE
authors.lastname: Barnes
authors.forename: Karla
authors.initials: K
authors.lastname: Lindquist
authors.forename: Brie A
authors.initials: BA
authors.lastname: Williams
authors.forename: Robert
authors.initials: R
authors.lastname: Brody
authors.forename: Dean
authors.initials: D
authors.lastname: Schillinger
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000523:psychology* / Q000706:statistics & numerical data; D001294:Attitude to Health; D002755:Choice Behavior; D032882:Comprehension; D032962:Consent Forms / Q000592:standards* / Q000706:statistics & numerical data; D004522:Educational Status; D005163:Factor Analysis, Statistical; D005260:Female; D005500:Follow-Up Studies; D007722:Health Knowledge, Attitudes, Practice; D006301:Health Services Needs and Demand; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D019303:Multilingualism; D015999:Multivariate Analysis; D010353:Patient Education as Topic / Q000706:statistics & numerical data; D012495:San Francisco; D011795:Surveys and Questionnaires