Understanding advance care planning as a process of health behavior change.
OBJECTIVE
To explore whether models of health behavior change can help to inform interventions for advance care planning (ACP).


METHODS
Qualitative cross-sectional study.


METHODS
Community.


METHODS
Sixty-three community-dwelling persons aged 65 and older and 30 caregivers with experience as surrogate decision-makers.


METHODS
In focus groups conducted separately with older persons and caregivers, participants were asked to discuss ways they had planned for future declines in health and why they had or had not engaged in such planning. Transcripts were analyzed using grounded theory.


RESULTS
Four themes illustrated the potential of applying models of health behavior change to improve ACP. (1) Participants demonstrated variable readiness to engage in ACP and could be in different stages of readiness for different components of ACP, including consideration of treatment goals, completion of advance directives, and communication with families and physicians. (2) Participants identified a wide range of benefits of and barriers to ACP. (3) Participants used a variety of processes of change to progress through stages of readiness, and ACP was only one of a broader set of behaviors that participants engaged in to prepare for declines in their health or for death. (4) Experience with healthcare decision-making for loved ones was a strong influence on perceptions of susceptibility and engagement in ACP.


CONCLUSIONS
The variability in participants' readiness, barriers and benefits, perceptions of susceptibility, and use of processes to increase readiness for participating in each component of ACP suggests the utility of customized, stage-specific interventions based on individualized assessments to improve ACP.
Fried
Terri R
TR
Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut, USA. terri.fried@yale.edu
Bullock
Karen
K
Iannone
Lynne
L
O'Leary
John R
JR
D032722:Advance Care Planning; D016223:Advance Directives / Q000523:psychology; D000368:Aged; D000369:Aged, 80 and over; D000375:Aging / Q000523:psychology*; D017028:Caregivers / Q000523:psychology; D003430:Cross-Sectional Studies; D003657:Decision Making; D005260:Female; D017144:Focus Groups; D015577:Geriatric Assessment; D006040:Goals; D015438:Health Behavior; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology; D011788:Quality of Life / Q000523:psychology; D020377:Self Efficacy
J Am Geriatr Soc. 2007 Feb;55(2):277-83
17302667
Dis Manag. 2006 Apr;9(2):102-14
16620196
BMJ. 1995 Jul 29;311(7000):299-302
7633241
Patient Educ Couns. 1995 Sep;26(1-3):353-61
7494750
J Palliat Med. 2004 Apr;7(2):341-9
15130215
Arch Intern Med. 1998 Dec 7-21;158(22):2493-7
9855388
Arch Intern Med. 1998 Apr 27;158(8):879-84
9570174
JAMA. 1995 Sep 13;274(10):820-5
7650806
J Gen Intern Med. 1998 Jul;13(7):439-46
9686709
J Gen Intern Med. 2002 Jan;17(1):48-57
11903775
Nurs Forum. 2004 Jul-Sep;39(3):5-12
15551794
J Consult Clin Psychol. 1988 Aug;56(4):520-8
3198809
Am J Public Health. 1994 Jan;84(1):43-9
8279610
Hastings Cent Rep. 2004 Mar-Apr;34(2):30-42
15156835
JAMA. 2001 Dec 19;286(23):2993-3001
11743841
Am J Geriatr Psychiatry. 2006 May;14(5):391-400
16670243
N Engl J Med. 2004 Jan 1;350(1):7-8
14702421
J Am Geriatr Soc. 2008 Jun;56(6):1006-13
18410324
J Gerontol B Psychol Sci Soc Sci. 2002 Nov;57(6):S348-54
12426443
J Palliat Med. 2002 Oct;5(5):697-704
12572968
J Gerontol B Psychol Sci Soc Sci. 2007 Mar;62(2):S135-41
17379683
Arch Intern Med. 2000 Jun 12;160(11):1690-6
10847263
J Adv Nurs. 1998 Aug;28(2):345-52
9725732
J Palliat Med. 2006 Feb;9(1):183-95
16430358
Am J Health Promot. 1997 Sep-Oct;12(1):38-48
10170434
Ann Intern Med. 1995 Oct 15;123(8):621-4
7677304
Addict Behav. 2001 Jul-Aug;26(4):583-602
11456079
J Am Geriatr Soc. 2009 Jan;57(1):31-9
19170789
J Am Geriatr Soc. 2005 Apr;53(4):711-9
15817022
Prev Med. 2003 Feb;36(2):150-8
12590989
Soc Sci Med. 2004 Jul;59(1):57-68
15087143
BMJ. 2002 Jul 20;325(7356):125
12130597
Ann Intern Med. 2007 Jul 3;147(1):51-7
17606961
Arch Intern Med. 2005 Mar 28;165(6):667-74
15795344