title: Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults.
abstract: OBJECTIVE
  To assess engagement in multiple steps of the advance care planning (ACP) process 6 months after exposure to an advance directive. In this study, ACP is conceptualized similarly to the behavior change model.
  
  
  METHODS
  Descriptive study.
  
  
  METHODS
  County general medicine clinic in San Francisco.
  
  
  METHODS
  One hundred seventy-three English or Spanish speakers, aged 50 and older (mean 61) given a standard (12th-grade reading level) and an easy-to-read (5th-grade reading level) advance directive.
  
  
  METHODS
  Six months after exposure to two advance directives, self-reported ACP contemplation; discussions with family, friends discussions with clinicians; and documentation were measured. Associations were examined between ACP steps and between subject characteristics ACP engagement.
  
  
  RESULTS
  Most participants (73%) were nonwhite and 31% had less than a high school education. Sixty-one percent contemplated ACP, 56% discussed ACP with family or friends, 22% discussed ACP with clinicians, and 13% documented ACP wishes. Subjects who had discussed ACP with their family or friends were more likely to discuss ACP with their clinicians (36% vs 2%, P<.001) and document ACP wishes (18% vs 4%, P=.009) than those who had not. Latinos and subjects with less than a high school education discussed ACP more often with family or friends (P<.06) and clinicians (P<.03) than other ethnic groups and subjects with more education.
  
  
  CONCLUSIONS
  ACP involves distinct steps including contemplation, discussions, and documentation. The ACP paradigm should be broadened to include contemplation and discussions. Promoting discussions with family and friends may be one of the most important targets for ACP interventions, and literacy- and language-appropriate advance directives may help reverse patterns of sociodemographic disparities in ACP.
authors.affiliation: Division of Geriatrics, University of California at San Franciso, and San Francisco Veterans Affairs Medical Center, San Francisco, California 94121, USA. rsucsf@yahoo.com
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Sudore
authors.forename: Adam D
authors.initials: AD
authors.lastname: Schickedanz
authors.forename: C Seth
authors.initials: CS
authors.lastname: Landefeld
authors.forename: Brie A
authors.initials: BA
authors.lastname: Williams
authors.forename: Karla
authors.initials: K
authors.lastname: Lindquist
authors.forename: Steven Z
authors.initials: SZ
authors.lastname: Pantilat
authors.forename: Dean
authors.initials: D
authors.lastname: Schillinger
mesh_terms: D032722:Advance Care Planning; D016223:Advance Directives; D000368:Aged; D003657:Decision Making; D004522:Educational Status; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008960:Models, Psychological; D015999:Multivariate Analysis; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D017060:Patient Satisfaction; D012495:San Francisco