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Angelo E. Volandes, MD; Lisa Soleymani Lehmann, MD, PhD, MSc; E. Francis Cook, ScD; Shimon Shaykevich, MSc; Elmer D. Abbo, MD, JD; Muriel R. Gillick, MD

Arch Intern Med. 2007;167(8):828-833.

Background  Advance care planning is a process by which patients plan for future medical care under circumstances of impaired decision-making. Central to this process is the patient's understanding and ability to imagine future health states.

Methods  A before and after oral survey was used to compare the effect of a video depiction with that of a verbal description of a patient with advanced dementia for individuals selecting level of medical care at 7 primary care clinics at 2 US medical centers. The study enrolled 120 adults, half of whom were nonwhite.

Results  A total of 120 subjects completed the interview. Before watching the video, 60 (50.0%) subjects preferred comfort care, 25 (20.8%) desired life-prolonging care, 22 (18.3%) chose limited care, and 13 (10.8%) were unsure of their preferences. Subject preferences changed significantly after the video: 107 (89.2%) of the subjects chose comfort care, none desired life-prolonging care, 10 (8.3%) chose limited care, and 3 (2.5%) were unsure of their preferences (P < .001). Unadjusted analysis revealed a statistically significant difference regarding preferences, based on race/ethnicity, before watching the video: 40% of African Americans and 43% of Latinos chose comfort care, compared with 58% of whites (P = .04). Differences were also noted for educational level (P = .03). After the video, differences in preferences based on race/ethnicity and educational level disappeared.

Conclusions  Watching the video significantly changed preferences for care, transcending apparent differences in preferences associated with race/ethnicity and educational level. This study suggests that using video in addition to improved verbal communication may lead to more informed advance care planning by enhancing the ability of patients to imagine a hypothetical health state.

Author Affiliations: Harvard Medical School (Drs Volandes, Lehmann, and Gillick), Department of Medicine, Brigham and Women's Hospital (Drs Volandes and Lehmann and Mss Cook and Shaykevich), Boston, Mass; Department of Medicine, University of Chicago, Chicago, Ill (Dr Abbo); and Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston (Dr Gillick). Dr Volandes is now with the General Medicine Unit, Massachusetts General Hospital, Boston.

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