The concept of advance care planning (ACP) is evolving. ACP was originally conceptualized as the process by which patients could specify in advance the treatment they would want to receive if they became decisionally incapable. Traditionally, it consisted of the completion of advance directives (AD). However, it has been shown that the completion of documents, while most likely necessary, is not in and of itself sufficient to improve end-of-life outcomes. This has led to newer conceptions of ACP as an act of communication, between patients and surrogates, and between patients and physicians, that focuses not on preferences for specific treatments but rather on broader goals of care. These newer conceptions achieve a number of important outcomes, including improving the quality of end-of-life decision-making, decreasing the burden associated with surrogate decision-making, and helping to ensure that the care patients receive at the end of life is consistent with their core values. Reviews of intervention studies to engage patients in ACP conclude that they have had only modest effects. The majority of interventions designed to increase rates of ACP participation have focused on the completion of ADs and also assume that patients are prepared for this participation. There is growing evidence, however, that individuals have variable readiness to participate, and that intervention materials aimed at persons who are ready to participate will not be effective for those at earlier stages of readiness. In this way, ACP is similar to many other health behaviors, for which models of health behavior change have served as the framework for successful interventions. This project builds upon a body of work demonstrating the applicability of the Transtheoretical Model (TTM) to ACP. The TTM is a model of health behavior change that has been used as the foundation for a large and growing number of effective interventions aimed at a wide range of behaviors. The current proposal seeks to develop an interactive, individualized, TTM-tailored intervention which can be delivered cost-effectively to large segments of a population, and at the same time, be tailored to individuals. In this proposal, ACP is defined as consisting of four components: 1) clarification of goals of care;2) communication with surrogates physicians regarding these goals;3) communication with physicians regarding these goals;and 4) completion of written documents.
The specific aims are: Primary Aim 1: To develop a TTM-tailored intervention designed to increase the rates of older persons'participation in ACP: Primary Aim 2: To determine the feasibility of the TTM intervention by pilot-testing procedures for delivering the intervention and assessing the acceptability and clarity of intervention materials. Primary Aim 3. To revise the intervention materials based on participants'feedback.

Public Health Relevance

Traditional approaches to interventions aimed at increasing rates of advance care planning focus are action- oriented;in other words, they provide steps that persons will take only if they are prepared or ready to participate. The proposed study, in contrast, seeks to develop an intervention providing steps for persons to take tailored to all stages of readiness. By meeting individuals'needs for behavior change, such an approach holds the promise of providing benefits to a larger portion of the population as compared to traditional intervention approaches.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Exploratory/Developmental Grants (R21)
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Special Emphasis Panel (ZRG1-CRE-B (01))
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Nielsen, Lisbeth
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Yale University
Internal Medicine/Medicine
Schools of Medicine
New Haven
United States
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