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A Randomized Controlled Trial

Peter H. Ditto, PhD; Joseph H. Danks, PhD; William D. Smucker, MD; Jamila Bookwala, PhD; Kristen M. Coppola, PhD; Rebecca Dresser, JD; Angela Fagerlin, PhD; R. Mitchell Gready, PhD; Renate M. Houts, PhD; Lisa K. Lockhart, PhD; Stephen Zyzanski, PhD

Arch Intern Med. 2001;161:421-430.

Background  Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions.

Participants and Methods  A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured.

Results  None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation.

Conclusions  Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.

From the Department of Psychology and Social Behavior, University of California, Irvine (Dr Ditto); Department of Psychology, Kent State University, Kent, Ohio (Drs Danks, Fagerlin, and Gready); Department of Family Practice, Summa Health System, Akron, Ohio (Dr Smucker); Department of Psychology, Pennsylvania State University, Abington (Dr Bookwala); Department of Psychology, Monmouth University, West Long Branch, NJ (Dr Coppola); Washington University Law and Medical Schools, St Louis, Mo (Ms Dresser); Center for Developmental Science, University of North Carolina, Chapel Hill (Dr Houts); Department of Psychology, Radford University, Radford, Va (Dr Lockhart); and Department of Family Medicine, Case Western Reserve University, Cleveland, Ohio (Dr Zyzanski).

Corresponding author: Peter H. Ditto, PhD, Psychology and Social Behavior, 3340 Social Ecology II, University of California, Irvine, CA 92697-7085 (e-mail: phditto{at}uci.edu).

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