Study on Advance Care Directives

Advance care directives are written legal documents in which individuals specify what types of medical care they would like to receive in the future should they lose the ability to make decisions for themselves. Behavioral economics suggests that individuals’ responses are susceptible to framing effects--or the manner in which information is presented--rather than the objective content of the information. It is possible that individuals’ responses to advance care directives are impacted by ordering effects, meaning that individuals’ responses vary with changes in the specific sequence in which questions and options are presented. However, there is no experimental evidence that isolates the role of question framing and ordering in the advance directive context, leaving a gap in the understanding of how question ordering may impact responses on these forms.

The purpose of this study is to examine whether individuals’ preferences for medical care and treatment as communicated on an advance directive form are impacted by the ordering of options and conditions. The primary objective is to determine whether participants are more likely to select that they would not prefer to receive certain treatments if the possible conditions are presented in differing orders of seriousness. To that end, we test whether individuals exhibit differences in medical care and treatment preferences, as identified on an advance care directive form, based on the order in which conditions and treatment options are presented to them. By varying the order in which options are presented to participants while holding the content of the questions constant, we seek to provide evidence directly relevant to improving individuals’ communication of their healthcare preferences.

The survey leverages four variations where participants will be randomly assigned one of the four variations. First, participants will be asked whether certain health conditions are acceptable or unacceptable. Half of the variations include an ordering where end-stage illness is the first condition while the other half lists permanent unconsciousness first. Next, participants will view treatments and be able to choose which treatments they would like to be given if they end up in a condition that is unacceptable to them. Half of the variations will allow a piece-wise choice, and the other half applies to all unacceptable conditions. After that section, there is a rationality test to see if the preferences for conditions are transitive.

We predict that respondents are more likely to indicate that they would not prefer to receive treatment if the possible conditions are presented in descending order of seriousness. Additionally, respondents are likely to have variable preferences for treatment when presented with treatment options for each condition as compared to when treatment options are presented in a single question that pertains to all conditions.