Respecting Choices® and advance directives in a diverse community

J Palliat Med. 2014 Mar;17(3):282-7. doi: 10.1089/jpm.2013.0047. Epub 2013 Dec 10.


Background: Respecting Choices® is a program designed and verified to improve advance care planning, yet it has not been tested in racially/ethnically diverse communities. Research has shown racial/ethnic minorities are less likely to have advance directives (ADs).

Objective: To determine whether Respecting Choices® would improve AD prevalence and utilization in a racially and ethnically diverse community.

Methods: The study design was that of a retrospective chart review. Subjects were all decedents from 2005 to 2010 (n=732) in a 300-bed Midwestern metropolitan hospital. Prevalence was assessed by the presence of an AD in the chart. Utilization was measured by the consistency of wishes expressed in an AD and treatment received ("No CPR," "No Feeding Tube," "No Antibiotics," "No Ventilator," "Comfort Care," and "Terminal Extubation"). Average treatment effect using regression analysis and matching on covariates was used for analysis of Respecting Choices® on AD prevalence. Proportional difference tests were used to compare consistency of wishes by race/ethnicity before and after Respecting Choices®.

Results: The prevalence of ADs increased significantly for racial and ethnic minorities after the implementation of Respecting Choices®: from 25.8% to 38.4% (p=0.011). The increase in AD prevalence for whites following Respecting Choices® was only marginal (46.7% to 47.3%; p=0.648), and the overall prevalence of ADs did not significantly change (35.9% to 42.9%; p=0.069). Consistency was high (74% to 96%) for all orders, and there were no significant differences following implementation of Respecting Choices® or between whites and racial and ethnic minorities.

Conclusions: The prevalence of ADs increased after Respecting Choices® was initiated in a racially and ethnically diverse community.

MeSH terms

  • Advance Directives* / ethnology
  • Advance Directives* / statistics & numerical data
  • Aged
  • Aged, 80 and over
  • Choice Behavior*
  • Female
  • Hospitals, Urban
  • Humans
  • Male
  • Medical Audit
  • Middle Aged
  • Palliative Care*
  • Patient Self-Determination Act
  • Professional-Patient Relations*
  • Retrospective Studies
  • United States