EXPANDED CHOICE SETS INCREASE PATIENTS' WILLINGNESS TO COMPLETE ADVANCE DIRECTIVES

Purpose: Previous research suggests that reframing decisions by expanding the number of options beyond two can influence choice through the innate human tendency to avoid perceived extremes in decision-making. We applied this theory to increase advance directive completion rates among patients with life-limiting illnesses. 

Method: In a randomized controlled trial among outpatients receiving chronic hemodialysis, patients were randomly assigned to two response options for the question of whether they would like to complete an advance directive: (1) the standard “yes or no” (“standard”) or (2) an expanded choice set that included three “yes” options varying only by comprehensiveness of the advance directive, thereby offering multiple options to say “yes” and one option to say “no” (“expanded”). Immediately after making their decision regarding advance directive completion, all patients completed the Satisfaction With Decision scale. We compared the proportions of patients willing to complete an advance directive across randomized groups using a chi-square test. Differences in decision satisfaction scores between groups were assessed using a Wilcoxon rank-sum test. 

Result: 252 patients (standard n=126; expanded n=126) were enrolled from 13 DaVita® clinics located throughout Philadelphia and Montgomery counties in Pennsylvania. 14.3% of patients reported previously discussing end-of-life preferences with their physician and 47.1% with their family. In the primary intention-to-treat analysis, 103 (82%) with an expanded choice set versus 88 (70%) with a standard choice set were willing to complete an advance directive (P=0.027). Patients were overall highly satisfied with the decision making process (4.17, IQR 4–5), and there was no difference in the Satisfaction With Decision score between those who received a standard versus an expanded choice set (P=0.97). 

Conclusion: Reframing decisions regarding advance directives increases patients’ reported willingness to complete one. Expanding choice sets is a promising mechanism to increase advance directive completion by gently leading chronically, seriously ill patients to choices most likely to promote their goals without restricting choice.