Improving a Full Range of Advance Care Planning Behavior Change and Action Domains: The PREPARE Randomized Trial

J Pain Symptom Manage. 2018 Oct;56(4):575-581.e7. doi: 10.1016/j.jpainsymman.2018.06.007. Epub 2018 Jun 27.


Context: Advance care planning (ACP) engagement includes a wide range of behaviors and actions related to discussions and documentation, yet few ACP intervention studies measure the full process.

Objectives: The objective of the study was to compare the effects of an easy-to-read advance directive (AD) versus an ACP web site plus the AD (PREPARE + AD) on Behavior Change Processes and Actions, including discussions and documentation.

Methods: Secondary data were from a completed ACP trial. Participants were primary care patients, ≥60 years old, with two comorbidities. We used the validated ACP Engagement Survey to examine six-month change in subscales measuring Behavior Change Processes (knowledge, contemplation, self-efficacy, readiness) and Actions (decision makers, quality of life, flexibility for decision makers, asking clinicians questions), specifically related to discussions and documentation. We used adjusted mixed-effects linear models to compare mean change and engagement over time.

Results: Compared to the AD-only, PREPARE + AD resulted in greater increases in all Behavior Change Processes subscales and Actions related to decision makers, quality of life, and flexibility (all P-values ≤0.005). Both interventions significantly increased the proportion of participants who engaged in ACP discussions (PREPARE + AD, 99.5%; AD-only, 93.3%) and documentation (PREPARE + AD, 99.5%; AD-only, 90.4%), with greater increases for PREPARE + AD (all P-values <0.001).

Conclusion: Both PREPARE plus an easy-to-read AD and an AD-only markedly increased ACP engagement in a full range of ACP behaviors, including discussions and documentation, and engagement was nearly 100% with PREPARE + AD. Future ACP studies should examine a full range of ACP behaviors beyond ADs and the impact of PREPARE and easy-to-read AD implementation on health care systems.

Trial registration: NCT01550731.

Keywords: Advance care planning; advance directive; behavior change; communication; decision aid.

Publication types

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

MeSH terms

  • Advance Care Planning*
  • Aged
  • Female
  • Health Communication
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Internet
  • Male
  • Patient Participation*
  • Primary Health Care
  • Quality Improvement
  • Reading
  • Treatment Outcome

Associated data