An advance directive redesigned to meet the literacy level of most adults: a randomized trial

Rebecca L Sudore, C Seth Landefeld, Deborah E Barnes, Karla Lindquist, Brie A Williams, Robert Brody, Dean Schillinger, Rebecca L Sudore, C Seth Landefeld, Deborah E Barnes, Karla Lindquist, Brie A Williams, Robert Brody, Dean Schillinger

Abstract

Objective: To determine whether an advance directive redesigned to meet most adults' literacy needs (fifth grade reading level with graphics) was more useful for advance care planning than a standard form (>12th grade level).

Methods: We enrolled 205 English and Spanish-speaking patients, aged >/=50 years from an urban, general medicine clinic. We randomized participants to review either form. Main outcomes included acceptability and usefulness in advance care planning. Participants then reviewed the alternate form; we assessed form preference and six-month completion rates.

Results: Forty percent of enrolled participants had limited literacy. Compared to the standard form, the redesigned form was rated higher for acceptability and usefulness in care planning, P</=0.03, particularly for limited literacy participants (P for interaction </=0.07). The redesigned form was preferred by 73% of participants. More participants randomized to the redesigned form completed an advance directive at six months (19% vs. 8%, P=0.03); of these, 95% completed the redesigned form.

Conclusions: The redesigned advance directive was rated more acceptable and useful for advance care planning and was preferred over a standard form. It also resulted in higher six-month completion rates.

Practice implications: An advance directive redesigned to meet most adults' literacy needs may better enable patients to engage in advance care planning.

Figures

Figure 1
Figure 1
Participant Flow Diagram
Figure 2. Standard Advance Directive
Figure 2. Standard Advance Directive
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. For more information, please visit our web site at www.caringinfo.org.
Figure 2. Standard Advance Directive
Figure 2. Standard Advance Directive
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. For more information, please visit our web site at www.caringinfo.org.
Figure 2. Standard Advance Directive
Figure 2. Standard Advance Directive
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. For more information, please visit our web site at www.caringinfo.org.
Figure 2. Standard Advance Directive
Figure 2. Standard Advance Directive
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. For more information, please visit our web site at www.caringinfo.org.
Figure 2. Standard Advance Directive
Figure 2. Standard Advance Directive
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. For more information, please visit our web site at www.caringinfo.org.
Figure 2. Standard Advance Directive
Figure 2. Standard Advance Directive
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. For more information, please visit our web site at www.caringinfo.org.
Figure 2. Standard Advance Directive
Figure 2. Standard Advance Directive
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. For more information, please visit our web site at www.caringinfo.org.
Figure 2. Standard Advance Directive
Figure 2. Standard Advance Directive
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. For more information, please visit our web site at www.caringinfo.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 3
Figure 3
Copyright, printing, and free download information is available on the Institute for Health Care Advancement’s website at www.iha4health.org.
Figure 4. Participant Ratings of Acceptability with…
Figure 4. Participant Ratings of Acceptability with the Redesigned and Standard Advance Directives
Participants assigned to the redesigned advance directive are indicated by the dark gray bar and the standard advance directive by the light gray bar. Participants rated their acceptability with the forms in three ways: ease of use and understanding (nine items) (P
All figures (22)

Source: PubMed

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