Default Options In Advance Directives Influence How Patients Set Goals For End-Of-Life Care

Health Affairs (Impact Factor: 4.97). 02/2013; 32(2):408-17. DOI: 10.1377/hlthaff.2012.0895
Source: PubMed


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.

Download full-text


Available from: Michael Harhay,
    • "Research has shown that in many situations people accept the default. This effect is present in both minor decisions such as online privacy settings (Johnson, Bellman, & Lohse, 2002) and more important decisions concerning pension savings (Thaler & Benartzi, 2004), end-of-life care (Halpern et al., 2013), and organ donation (Johnson & Goldstein, 2003). The effect of defaults on behavior is caused by a number of different processes, including effort reduction, implied endorsement, and the unwillingness to give up the status quo when it is understood as an endowment (Dinner et al., 2011; McKenzie et al., 2006). "
    [Show abstract] [Hide abstract]
    ABSTRACT: We present a taxonomy of choice architecture techniques that focus on intervention design, as opposed to the underlying cognitive processes that make an intervention work. We argue that this distinction will facilitate further empirical testing and will assist practitioners in designing interventions. The framework is inductively derived from empirically tested examples of choice architecture and consists of nine techniques targeting decision information, decision structure, and decision assistance. An inter-rater reliability test demonstrates that these techniques can be used in an intersubjectively replicable way to describe sample choice architectures. We conclude by discussing limitations of the framework and key issues concerning the use of the techniques in the development of new choice architectures.
    Journal of Behavioral Decision Making 08/2015; DOI:10.1002/bdm.1897 · 2.84 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: A grassroots group teams up with health care providers to transform the way Americans deal with care choices near the end of life.
    Health Affairs 02/2013; 32(2):203-6. DOI:10.1377/hlthaff.2012.1174 · 4.97 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Most major decisions in the intensive care unit (ICU) regarding goals of care are shared by clinicians and someone other than the patient. Multicenter clinical trials focusing on improved communication between clinicians and these surrogate decision makers have not reported consistently improved outcomes. We suggest that acquired maladaptive reasoning may contribute importantly to failure of the intervention strategies tested to date. Surrogate decision makers often suffer significant psychological morbidity in the form of stress, anxiety, depression, and post-traumatic stress disorder. Family members in the ICU also suffer cognitive blunting and sleep deprivation. Their decision-making abilities are eroded by anticipatory grief and cognitive biases, while personal and family conflicts further impact their decision making. We propose recognizing a family ICU syndrome to describe the morbidity and associated decision-making impairment experienced by many family members of patients with acute critical illness (in the ICU) and chronic critical illness (in the long-term, acute care hospital). Research rigorously using models of compromised decision making may help elucidate both mechanisms of impairment and targets for intervention. Better quantifying compromised decision making and its relationship to poor outcomes will allow us to formulate and advance useful techniques. The use of decision aids and improving ICU design may provide benefit now and in the near future. In measuring interventions targeting cognitive barriers, clinically significant outcomes, such as time to decision, should be considered. Statistical approaches, such as survival models and rank statistic testing, will increase our power to detect differences in our interventions.
    Annals of the American Thoracic Society 03/2014; 11(3):435-41. DOI:10.1513/AnnalsATS.201309-308OT
Show more