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Results of a Multifaceted Intervention

Robert A. Pearlman, MD, MPH; Helene Starks, MPH, PhD; Kevin C. Cain, PhD; William G. Cole, PhD

Arch Intern Med. 2005;165:667-674.

Background  Advance care planning (ACP) aims to guide health care in the event of decisional incapacity. Interventions to promote ACP have had limited effectiveness. We conducted an educational and motivational intervention in Department of Veterans Affairs outpatient clinics to increase ACP use and proxy and health care provider understanding of patients’ preferences and values.

Methods  We recruited 23 providers and up to 14 of each of their patients; the patients were randomized to the control or intervention group. Eligibility criteria included a preexisting relationship with the provider, age 55 years or older, chronic health condition(s), and no recorded advance directive. The intervention group (n = 119) received an ACP workbook, motivational counseling by social workers, and cues to providers to discuss ACP. The control group (n = 129) received an advance directive booklet.

Results  The intervention patients reported more ACP discussions with their providers (64% vs 38%; P<.001). Living wills were filed in the medical record twice as often in the intervention group (48% vs 23%; P<.001). Provider-patient dyads in the intervention group had higher agreement scores than the control group for treatment preferences, values, and personal beliefs (58% vs 48%, 57% vs 46%, and 61% vs 47%, respectively; P<.01 for all comparisons). The agreement scores for the proxy-patient dyads did not differ between groups for treatment preferences and values, but were higher in the intervention than the control group for personal beliefs (67% vs 56%).

Conclusion  This intervention demonstrates mixed results and highlights the ongoing challenges of helping health care providers and potential proxy decision makers represent patient preferences and values.

Author Affiliations: Veterans Affairs Puget Sound Health Care System, Seattle Division (Dr Pearlman), and Departments of Medicine (Dr Pearlman), Medical History and Ethics (Drs Pearlman and Starks), Health Services (Drs Pearlman and Starks), and Biostatistics (Dr Cain), University of Washington, Seattle; and Department of Psychology, Lewis & Clark College, Portland, Ore (Dr Cole).

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