An advance directive redesigned to meet the literacy level of most adults: a randomized trial

Patient Educ Couns. 2007 Dec;69(1-3):165-95. doi: 10.1016/j.pec.2007.08.015. Epub 2007 Oct 17.


Objective: To determine whether an advance directive redesigned to meet most adults' literacy needs (fifth grade reading level with graphics) was more useful for advance care planning than a standard form (>12th grade level).

Methods: We enrolled 205 English and Spanish-speaking patients, aged >/=50 years from an urban, general medicine clinic. We randomized participants to review either form. Main outcomes included acceptability and usefulness in advance care planning. Participants then reviewed the alternate form; we assessed form preference and six-month completion rates.

Results: Forty percent of enrolled participants had limited literacy. Compared to the standard form, the redesigned form was rated higher for acceptability and usefulness in care planning, P</=0.03, particularly for limited literacy participants (P for interaction </=0.07). The redesigned form was preferred by 73% of participants. More participants randomized to the redesigned form completed an advance directive at six months (19% vs. 8%, P=0.03); of these, 95% completed the redesigned form.

Conclusions: The redesigned advance directive was rated more acceptable and useful for advance care planning and was preferred over a standard form. It also resulted in higher six-month completion rates.

Practice implications: An advance directive redesigned to meet most adults' literacy needs may better enable patients to engage in advance care planning.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Advance Directives / psychology*
  • Advance Directives / statistics & numerical data
  • Attitude to Health*
  • Choice Behavior*
  • Comprehension
  • Consent Forms / standards*
  • Consent Forms / statistics & numerical data
  • Educational Status*
  • Factor Analysis, Statistical
  • Female
  • Follow-Up Studies
  • Health Knowledge, Attitudes, Practice
  • Health Services Needs and Demand
  • Humans
  • Income
  • Male
  • Middle Aged
  • Multilingualism
  • Multivariate Analysis
  • Patient Education as Topic / statistics & numerical data
  • San Francisco
  • Surveys and Questionnaires