Default options in advance directives influence how patients set goals for end-of-life care

Abstract

Although decisions regarding end-of-life care are personal and important, they may be influenced by the ways in which options are presented. To test this hypothesis, we randomly assigned 132 seriously ill patients to complete one of three types of advance directives. Two types had end-of-life care options already checked-a default choice-but one of these favored comfort-oriented care, and the other, life-extending care. The third type was a standard advance directive with no options checked. We found that most patients preferred comfort-oriented care, but the defaults influenced those choices. For example, 77 percent of patients in the comfort-oriented group retained that choice, while 43 percent of those in the life-extending group rejected the default choice and selected comfort-oriented care instead. Among the standard advance directive group, 61 percent of patients selected comfort-oriented care. Our findings suggest that patients may not hold deep-seated preferences regarding end-of-life care. The findings provide motivation for future research examining whether using default options in advance directives may improve important outcomes, including patients' receipt of wanted and unwanted services, resource use, survival, and quality of life.

EXHIBIT 2

Percentage Of Patients Choosing A Comfort-Oriented Goal Of Care (Per Protocol Population) SOURCE Authors’ analysis. NOTES Standard error bars denote 95% confidence intervals..

EXHIBIT 3

Percentage Of Patients Choosing To Forgo Each Intervention, By Type Of Advance Directive (Per Protocol Population) SOURCE Authors’ analysis. NOTES Standard error bars denote 95% confidence intervals. CPR is cardiopulmonary resuscitation.