Doctors and patients have shown a heightened interest in advance care planning to avoid conflict at the end of life. We hypothesized that supplementing verbal descriptions with video would alter patients' advance care planning decisions in regards to advanced dementia. We compared the effect of a video depiction of a patient with advanced dementia to a verbal description of the disease for individuals selecting level of medical care if in the state of advanced dementia.
We conducted a before and after oral survey at seven outpatient primary care clinics at two U.S. medical centers in the greater Boston area. The study was conducted from November 2005 to February 2006 and enrolled 120 adults, half of whom were non-White. A two-minute video depicting a real patient with advanced dementia was used as the supplemental video. The video was available in both English and Spanish. (The film clip is available online at: http://www.brighamandwomens.org/ethics/patientresources.aspx). The main outcome measure was change in preferences for one of three levels of medical care (life prolonging, limited, and comfort care) in advanced dementia after viewing the video.
A total of 120 subjects completed the interview. Before seeing the video, 60 (50%) subjects preferred comfort care; 25 (21%) desired life-prolonging care; 22 (18%) chose limited care; and 13 (11%) were unsure of their preferences. The subjects' preferences changed significantly after the video: 107 (89%) of the subjects chose comfort care; none desired life-prolonging care; 10 (8%) chose limited care; and, 3 (3%) were unsure of their preferences (p<.001). Unadjusted analysis revealed a statistically significant difference regarding preferences based on race/ethnicity before the video: 40% of African-Americans and 43% of Latinos chose comfort care, compared to 58% of Whites (p=.04). Differences were also noted for education (p=.03). After the video, the differences based on race/ethnicity and education disappeared.
Video significantly changed preferences for care, transcending apparent differences associated with race/ethnicity and education. This study suggests that differences in patient preferences may be an artifact of insufficient comprehension using verbal methods alone. Using video in addition to improved verbal communication may lead to more informed advance care planning.