Advance care planning (ACP), the process by which individuals and their healthcare surrogate can prepare for future treatment decisions, remains underutilized. ACP addresses many of the issues that patients and their caregivers endorse as important in end-of-life care. However, there are many emotional, cognitive, and practical barriers to engaging in ACP. While it has been demonstrated that intervention can increase ACP engagement, this model require a skilled, well-trained moderator meeting with patients and caregivers in lengthy encounters. This type of intensive intervention may be best suited for patients with serious chronic illnesses who are ready to think about their specific disease trajectories and the decisions they are likely to face. The recent Institute of Medicine (IOM) report Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life proposes a continuous process of ACP, starting earlier in the lifespan with individuals in good health and an initial focus on identification of a surrogate decision maker and general communication about patients' goals with more in-depth and specific discussions coming later. This proposal describes the evaluation of an intervention to promote initial engagement in ACP. Taking a public health approach to ACP engagement, the intervention is designed to be able to reach a broad cross-section of individuals at modest expense. The intervention considers ACP to be a health behavior, to which the Trans theoretical Model (TTM) of health behavior change is applicable. The TTM provides a framework for the delivery of tailored intervention materials based on an assessment of an individual's readiness to engage in ACP along with the attitudes and beliefs influencing the desire, motivation, and ability to engage. The PI and her co-investigators have developed a TTM-tailored expert system intervention with stage-targeted brochures and demonstrated the acceptability of these materials to a diverse cohort of older adults. The proposed study represents the logical next steps in this work, by examining the ability of the intervention to reach a wide audience and increase readiness to engage in ACP.
The specific aims of the current proposal are: Primary Aim 1: Utilizing a randomized controlled trial, to examine the effect of an individually TTM-tailored intervention on the proportion of middle-age and older persons who complete ACP, as compared with usual care. Primary Hypothesis 1: The proportion of older persons completing ACP will be higher among those receiving the intervention compared to persons receiving usual care. Primary Aim 2: To examine the ability to deliver the intervention to a wide cross-section of individuals. Primary Hypothesis 2: Among eligible persons, ? 80% will participate in the intervention.

Public Health Relevance

Advance care planning (ACP), the process by which individuals and their healthcare surrogate can prepare for future treatment decisions, remains underutilized. This project describes an intervention to increase rates of engagement in ACP by delivering individually tailored materials aimed at addressing the emotional, cognitive, behavioral, and practical barriers to ACP engagement.

National Institute of Health (NIH)
National Institute of Nursing Research (NINR)
Research Project (R01)
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Special Emphasis Panel (ZRG1)
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Kehl, Karen
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Yale University
Internal Medicine/Medicine
Schools of Medicine
New Haven
United States
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