Promoting Advance Directives for Health Care and Research Through a Single‐ or MultiSession Intervention: Does it Affect Completion Rates and Content?

To the Editor: In a recent trial,1 the effects of promoting a combined healthcare and research advance directive (AD) to older adults were assessed. Three activities were organized for each group.2 For the experimental group, these were a first home visit by a trained facilitator who helped older adults communicate their wishes to their proxies, a group information session on ADs during which participants were introduced to a booklet designed for recording wishes, and a second home visit by the same facilitator who assisted interested older adults in completing the booklet. Meanwhile, control participants attended three nurse-led workshops promoting healthy behaviors. At the request of the research ethics board, control participants who were still present at the end of the trial were invited to attend the group session on ADs. This request provided a unique opportunity to compare a single-session intervention on AD completion rate and content with a multisession intervention. Systematic reviews of earlier trials suggest that providing oral information on ADs and assistance with their completion over multiple sessions are important attributes of successful interventions,3 although this conclusion is based on between-study comparisons that cannot support causation. Whether offering multiple sessions affects AD completion rate and content is thus unknown. Addressing this knowledge gap is important, because interactive interventions that span several sessions are labor intensive. The trial involved 235 adults (mean age 77, 54% male) and their self-selected proxies (67% spouses). Of the 118 participants allocated to the experimental group, 95 were present at the end of the trial. In the control group, 90 of the 117 allocated participants remained at the end, and 39 of these attended the information session on ADs. One month after participants' last scheduled activity, a photograph was taken of completed booklets to establish completion rates and summarize contents. A 95% confidence interval (CI) around the difference in completion rates was computed to compare groups on this outcome. The Fisher exact test was used to compare booklet content. Older adults exposed to the multi- and single-session interventions did not differ significantly on any of the variables measured at baseline. Ninety-four (80%) participants attending the multisession intervention completed the directive,1 versus 32 (82%) of those who attended only the information session (95% CI = −12–16%). Wishes expressed in the directive did not differ significantly between groups (Table 1). Most participants stated a preference for prioritizing comfort; 63% expressed a desire to enroll in research should they be solicited after losing decisional capacity. Findings suggest that a single-session intervention conducted in groups and aimed at informing older adults and proxies of the benefits and limitations of healthcare and research ADs may be as effective as an intervention spanning three sessions and involving direct interactions with a facilitator in stimulating completion and lead to similar sets of wishes. In both groups, four of five completed the booklet, a rate much higher than in past experimental research on healthcare directives.4, 5 Only two studies that promoted research directives were found.6, 7 Both yielded low completion rates (16% and 11%, respectively). Most of the current study participants stated a preference to prioritize comfort and forgo life-sustaining treatments, as reported by others.4, 8, 9 Nearly two-thirds expressed a willingness to engage in low-risk studies. The authors know of no publication reporting on choices made in a research directive and hence cannot compare this finding with those of others. The facilitator had an important role to play, including helping older adults communicate their wishes to their proxies and assisting those interested in recording wishes, yet these interactions did not lead older adults to make different choices regarding future health care and research involvement. Because these activities were conducted individually rather than in groups, they were costly and challenging to organize. Results suggest that the assistance provided during the group information session was sufficient to motivate and guide participants in recording their preferences. Whether interacting with the facilitator better prepares proxies to make substitute decisions on behalf of an incompetent older adult should be investigated in the future, with attention paid to healthcare and research decisions. ADs completed in isolation have been found to provide little guidance to surrogates who are later called upon to make substitute decisions.10 Timely access by surrogates to completed ADs is also known to be problematic. Older adults and proxies attended the group information session. Further research is needed to determine whether this feature of the intervention allows proxies to gain better insight into recorded wishes. The authors would like to thank Suzanne Bellemare and Karen Painter for their assistance in implementing the study, recruiting participants, and organizing the home visits and group information sessions. Conflict of Interest: The authors declare no conflicts of interest. This work was supported by Canadian Institutes of Health Research (CIHR) Grant 200809MCT-190832-RSA. Author Contributions: Bravo, Arcand, Dubois, Guay, Boire-Lavigne, Hottin: planning the study, securing funding, design of interventions and booklet. Trottier: statistical analyses. Bravo: writing the letter. All authors: final approval. Sponsor's Role: CIHR approved the study design but played no role in data collection, statistical analysis, interpretation, or writing of the manuscript.

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