STRATEGIES TO PROMOTE THE USE OF ADVANCE DIRECTIVES IN A RESIDENCY OUTPATIENT PRACTICE

OBJECTIVE: To evaluate patient education and resident education strate gies to promote advance directives in the outpatient setting, and to a ssess barriers to implementation. DESIGN: Controlled clinical trial. S ETTING: The internal medicine residents' practice of an urban, univers ity medical center. PATIENTS/PARTICIPANTS: Medical residents and 250 p atients seen at least twice in the 3 months prior to the study. INTERV ENTIONS: We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, an d videotaping of an actual discussion by each resident, followed by in dividual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discu ss advance directives. MEASUREMENTS AND MAIN RESULTS: We interviewed 1 87 of these patients (response rate 75%) and surveyed 62 residents (re sponse rate 70%). After 18 months, there were no significant differenc es in the number of advance directives in charts among the three group s. Documented advance directives discussions with patients in the resi dent education group increased from 3% to 17% (p < .001), more than th ose in the patient education (5%) or control group (10%, p = .04), Res idents in the resident education group were more likely to report disc ussing advance directives than those in the patient education or contr ol groups (p = .05). Lack of time (95%) and lack of continuity (76%) w ere the most frequently cited barriers. In multivariate logistic regre ssion, nonwhite race and non-U.S. birth were negatively associated wit h patient interest in advance directives. Patient race and birthplace were not associated with actual discussions of advance directives. CON CLUSIONS: Even with intensive efforts to educate outpatients and resid ents about advance directives, important barriers remain, raising ques tions about how best to promote advance directives among outpatients.