Advance directives as acts of communication - A randomized controlled trial

Background: Instructional advance directives are widely advocated as a mean s of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-su staining treatment wishes. However, no research has examined whether instru ctional directives are effective in improving the accuracy of surrogate dec isions. Participants and Methods: A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% chil dren) were randomized to 1 of 5 experimental conditions. In the control con dition, surrogates predicted patients' preferences for 4 life-sustaining me dical treatments in 9 illness scenarios without the benefit of a patient-co mpleted advance directive. Accuracy in this condition was compared with tha t in 4 intervention conditions in which surrogates made predictions after r eviewing either a scenario-based or a value-based directive completed by th e patient and either discussing or not discussing the contents of the direc tive with the patient. Perceived benefits of advance directive completion w ere also measured. Results: None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogat e understanding and comfort for patient-surrogate pairs in which the patien t had not completed an advance directive prior to study participation. Conclusions: Our results challenge current policy and law advocating instru ctional advance directives as a means of honoring specific patient wishes a t the end of life. Future research should explore other methods of improvin g surrogate decision making and consider the value of other outcomes in eva luating the effectiveness of advance care planning.