End-of-Life Planning Education and Advance Directives Completion Rates

Dear Editor:

We reviewed with interest the study by Oulton et al. on the prevalence of advance directives (ADs) among older adults presenting to emergency departments (EDs). ¹ We agree that observed rates of AD completion are low for all populations, and there is room for improvement. Provisions in the Patient Self-Determination Act are essential but not sufficient to increase AD completion rates. The most frequently reported reason for not having an AD is lack of awareness. ² Different intervention approaches to improve awareness among consumers have met with varying degrees of success in increasing rates of AD completion. ³

We tested the effectiveness of end-of-life (EOL) planning education in improving AD completion rates. EOL planning education was delivered in the setting of employer-sponsored financial planning seminars through two different channels of delivery: online webinars and in-person workshops. Results were measured and reported in three groups: webinar participants, workshop participants, and a historic control group comprised of individuals who had participated in similar financial planning webinars/workshops in the prior 12 months, which did not contain EOL content (see Fig. 1).

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FIG 1.

Advance directives completion rates by study group (%).

AD completion rates were measured based on responses to surveys administered immediately preceding and at least 60 days following each webinar/workshop. Surveys were also administered once to individuals identified in the historic control group. We compared the self-reported rates of AD completion before and after webinars and workshops. We also compared these rates to those of the historic control group. In addition we measured the change in AD completion rates in each cohort of participants from before the event to after participation. We compared the lift in AD completion rates between the webinar and workshop groups. The Z test was used to determine statistical significance in the observed differences.

Participants in webinars numbered 703, of which 267 (38%) completed pre-webinar surveys—87 (33%) of those had completed ADs. Of 113 (16%) completing post-webinar surveys, 41 (36%) reported AD completion. The pre-post delta for AD completion in the webinar group was 3.7% (p = 0.56).

Participants in workshops numbered 158, of which 110 (70%) completed pre-workshop surveys—40 (36%) of those had completed ADs. Of 51 (32%) completing post-workshop surveys, 24 (47%) reported AD completion. The pre-post delta for AD completion in the workshop group was 10.7% (p = 0.19). The pre-post delta for AD completion for workshop participants (10.70%) was significantly higher than that of webinar participants (3.70%) (p < 0.001). Out of 662 participants in the historic control group, 308 (47%) completed the survey; 108 (35%) had completed ADs.

Although our study did not demonstrate statistically significant improvement in AD completion after delivery of EOL planning education in the context of consumer financial planning, there was a trend towards improvement in AD completion rates, particularly in workshop participants. Larger studies are needed to demonstrate significant improvement in AD completion rates from EOL education in the context of consumer financial education. Providing information to patients in EDs by itself is unlikely to drive increase in AD completion. More robust consumer education initiatives are required to make a meaningful impact.