title: A Randomized Trial of Expanding Choice Sets to Motivate Advance Directive Completion.
abstract: Evidence suggests that advance directives may improve end-of-life care among seriously ill patients, but improving completion rates remains a challenge.
  
  
  
  This study tested the influence of increasing the number of options for completing an advance directive among seriously ill patients.
  
  
  
  Outpatients ( N = 316) receiving hemodialysis across 15 dialysis centers in the Philadelphia region between July 2014 and July 2015 were randomized to receive either the option to complete a brief advance directive form or expanded options including a brief, expanded, or comprehensive form. Patients in both groups could decline to complete an advance directive or take their selected version home. The primary outcome was a returned, completed advance directive. Secondary outcomes included whether patients wanted to complete an advance directive, decision satisfaction, quality of life at 3 months, and patient factors associated with advance directive completion.
  
  
  
  Although offering more advance directive options was not significantly associated with increased rates of completion (13.1% in the standard group v. 12.2% in the expanded group, P = 0.80), it did significantly increase the proportion of patients who wanted to complete an advance directive and took one home (71.9% in standard v. 85.3% in expanded, P = 0.004). There was no difference in satisfaction ( P = 0.65) or change in quality of life between groups ( P = 0.63). A higher baseline quality of life was independently associated with advance directive completion ( P = 0.006).
  
  
  
  These results suggest that although an expanded choice set may initially nudge patients toward completing advance directives without restricting choice, increasing actual completion requires additional interventions that overcome downstream barriers.
authors: Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, PA (KRC, SDH).|Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).
authors: Katherine R
authors: KR
authors: Courtright
authors: Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).|Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH).
authors: Vanessa
authors: V
authors: Madden
authors: Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).|Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH).
authors: Nicole B
authors: NB
authors: Gabler
authors: Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).|Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH).
authors: Elizabeth
authors: E
authors: Cooney
authors: Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).
authors: Jennifer
authors: J
authors: Kim
authors: Department of Medicine, Boston University Medical Center, Boston, MA (NH).
authors: Nicole
authors: N
authors: Herbst
authors: Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).
authors: Lauren
authors: L
authors: Burgoon
authors: Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (JW, SDH).
authors: Jennifer
authors: J
authors: Whealdon
authors: Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA (LMD).
authors: Laura M
authors: LM
authors: Dember
authors: Pulmonary, Allergy and Critical Care Division, University of Pennsylvania, Philadelphia, PA (KRC, SDH).|Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, PA (KRC, VM, NBG, EC, JK, LB, SDH).|Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA (VM, NBG, EC, SDH).|Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA (JW, SDH).
authors: Scott D
authors: SD
authors: Halpern
mesh_terms: D000328:Adult; D016223:Advance Directives; D000368:Aged; D000554:Ambulatory Care Facilities; D002755:Choice Behavior; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015143:Philadelphia; D006435:Renal Dialysis
keywords: advance care planning; advance directive; behavioral economics; end of life