This is a project designed to test the effectiveness of a comprehensive program to promote care planning and the use of ADs, in a community-based approach in four different settings. The program includes a home-based decision kit, supportive telephone counselling by trained staff, and contacts between those who complete ADs and their personal health care professionals. This kit has already been developed and has undergone initial testing as part of a cooperative arrangement between the American Association of Critical Care Nurses (AACCN) and the Institute for Prevention Research at the University of Southern California. Three major outcomes will be measured: 1) whether individuals engage in thoughtful planning about their future care options; 2) whether individuals complete a valid AD; and 3) whether individual care preferences remain stable over time. The program and research into the outcomes are embedded in a field experimental design that manipulates two elements of human decision making held to be crucial by contemporary psychological researchers. The first element to be experimentally manipulated is subjective social norms, or awareness that others are taking the recommended action. Some participants will be enrolled as members of already existing social groups from the community. Others will be enrolled from lists of the patients or clients of various health care professionals. This is supported by the Theory of Reasoned Action (Ajzen and Fishbein). The second element to be manipulated will be the framing of the information about ADs. For one group, the emphasis will be on the losses which can result from not taking action. For the other group, the emphasis will be on the gains which can be realized by taking action. This is supported by the Prospect Theory (Kahneman and Tversky). The experimental design provides for lagged controls that eventually take part in the treatment protocols. Subjective social norms will be manipulated at two of the four sites (California and Iowa). Framing will be manipulated at another site (Pennsylvania). The fourth site (East Los Angeles) will be used to test a culturally specific program in Spanish for Hispanics of Latin American Descent. A total of 28 intact groups and other organizations will join the project, and 3,000 individual participants will be interviewed. Half of those who actually complete ADs among the group in California will have these ADs validated through contacts with personal physicians. The people who complete ADs will be re-interviewed 12 months afterwards to gauge the stability of these care preferences over time. The sites chosen for study present a variety of legal frameworks and a variety of social and economic conditions.
