Deferring Agency at End-of-Life: The Role of Information and Advance Directives

We propose to pilot a randomized evaluation of strategies to facilitate advance directive completion in the 65+ patient population of our partner, Providence St. Joseph Health. Despite the significant economic and personal implications of end-of-life health care decisions, many people fail to document their wishes or to select a representative who can make medical decisions on their behalf. Descriptive evidence suggests that this results in sub-optimal outcomes including dissatisfaction and potentially unnecessary medical spending. However, it is not well understood why patients fail to engage in this apparently high-value planning. Our trial will pilot two interventions with roughly 5,000 patients, with intention to scale the evaluation to include over 70,000 patients across 64 clinics. We will evaluate the effects of (i) an in-person drive to facilitate advance directive completion, (ii) an informational video on advance directives that will be electronically distributed to patients, and (iii) the interaction of these two interventions. Key outcomes will include advance directive completion rates, decisions made on advance directive forms, and eventually observed care decisions. We will also leverage surveys and granular data on patient health to better understand barriers to advance care planning and relate to underlying economic theory that explains behavior.