Effect of the Contents in Advance Directives on Individuals’ Decision-Making

Abstract

Completing an advance directive offers individuals the opportunity to make informed choices about end-of-life care. However, these decisions could be influenced in different ways depending on how the information is presented. We randomly presented 185 participants with four distinct types of advance directive: neutrally framed (as reference), negatively framed, religiously framed, and a combination. Participants were asked which interventions they would like to receive at the end of life. Between 60% and 70% of participants responded “accept the special interventions” on the reference form. However, the majority (70%–90%) chose “refuse the interventions” on the negative form. With respect to the religious form, 70% to 80% chose “not decided yet.” Participants who refused special life-sustaining treatments were older, female, and with better prior knowledge about advance directives. Our findings imply that the specific content of advance directives could affect decision-making with regard to various interventions for end-of-life care.

Keywords

advance directives decision-making end-of-life care informed decision framing effect

According to game theory, people make decisions based on the values and probabilities inherent in a situation. Thus, it is possible to predict what kind of action an individual will choose if every possible value and probability are known in a specific situation. Game theory was conceived as a normative model that postulated an idealized and rational agent as a decision maker. However, Tversky and Kahneman (1981) claimed that the behaviors of real people do not follow the assumptions of game theory. They demonstrated that the framing of alternatives can significantly affect decision-making. This means that the “framing effect,” that is, the way an object is presented or how information is worded and phrased, can prompt an irrational and emotional reaction that, in turn, influences a particular decision. Several psychologists also demonstrated that a person’s cognition could be affected by the content(s) of a situation or condition, which can determine the information processing that people use in making choices. For example, Rettinger and Hastie (2001) revealed that, despite using the same measures of the subjective values and probabilities of the options, casino gambling as a metaphor for game theory was associated with different behaviors than in the following content-domain scenarios: legal traffic tickets, financial stock investment, and academic course grades. Most participants preferred the safe option and adopted an avoid-the-risk strategy in the gambling scenario but chose the risky option and calculation strategy in the stock scenario. Their choice between risk-prone and risk-averse options was almost equal in academic and legal scenarios. A morality strategy was used more often in the legal scenario. Considering mental representations, more of the total propositions were recalled in the legal scenario. Number propositions were recalled more frequently in the legal and stock scenarios. The results demonstrated a fundamental role of content in the process of decision-making through affecting judgments, decision strategies, mental representations, and the ultimate choice (Rettinger & Hastie, 2001).

An advance directive is a legal document in which a competent person makes provision for medical and health-care decisions in the event she or he becomes mentally incompetent to make such decisions (Culver & Gert, 1990). Advance directives provide instructions to help a person make free and informed choices. However, according to the notion of framing effects, it is possible that medical decisions could be influenced in different ways depending on how the information in an advance directive is presented. This diversity of language could potentially affect an individual’s perception in regard to his or her end-of-life care at an unconscious level; this may nullify the original goal of advance directives, which implies the right to a dignified death by one’s own choice. Therefore, this study evaluated the influence of the specific content of advance directives on decisions related to end-of-life care options.

Methods

Study Participants

One hundred and eighty-five community-dwelling people participated in this study. Subjects were recruited from seven different community centers in Seoul, South Korea. With permission, we visited regular meetings at the centers and explained the aims of the study to attendants. Subjects who were willing to participate were included if they were more than 18 years old and competent to make a decision. We excluded subjects who were health-care professionals and those who lacked decisional capacity, including those with severe dementia. Of the 200 questionnaires distributed, 185 were returned and the valid response rate was 100%.

Study Design

Between August 2016 and July 2017, we conducted a survey using a structured questionnaire outlining four scenarios of advance directives and a variety of life-sustaining interventions. The questionnaire was designed and validated based on a pilot study (copies of the questionnaire are available on request). The advance directives were presented in four different ways. The first, the “reference form,” was neutrally worded and excluded emotional or religiously framed words or content (Table 1). It provided an objective description and information related to advance directives and end-of-life care. The second was a negatively framed form that described aspects of life-sustaining treatment that might be interpreted as burdensome and unwanted, such as severe pain, serious risks, or complications, which were added to the reference form. The third was a religiously framed form in which religious teachings about the sanctity of life were attached to the reference form. The fourth “combined form” included the reference form and both negative and religious content.

Table 1.

Outline of Four Distinctive Forms of Advance Directive.

	Reference	Negative	Religious	Combined
Part I. Introduction	1. Objective description about advance directive 2. Clear and impartial explanation of LST and end-of-life care	Reference form plus 1. Negative aspects of LST including severe pain and complications 2. Emotional words such as futile, burden, vegetative, and meaningless, and so on	Reference form plus 1. Religious teaching about life and death: respect for life and sanctity of life 2. religious terms including God’s will and sin, and so on	Reference form plus All of the contents in both negative and religious forms
Part II. Various options for end-of-life care	1. List of LST 2. Spiritual and psychological supports	Same as the reference form	Same as the reference form	Same as the reference form

Note. LST = life-sustaining treatments.

Life-sustaining treatments were divided into special and general forms based on the necessity of specialized medical knowledge and specific medical devices, equipment, or facilities. General life-sustaining treatment consisted of providing nutrition and hydration, oxygen supply, maintaining temperature, helping with voiding and defecation, preventive measures for pressure ulcers, pain control, and so on. Special life-sustaining treatment included cardiopulmonary resuscitation (CPR), ventilator, dialysis, inotropics, and so on. This differentiation was established by the Guidelines Enactment Special Committee in Korea (Lim, Hong, & Lee, 2015). In addition, psychological and spiritual or religious counseling were added to the list as options that participants could choose for their end-of-life care.

We also collected demographic data including age, gender, religion, and political leanings and examined the degree of importance of participants’ religious and political viewpoints on decision-making, and whether participants were well-informed about end-of-life care. The degree of importance of religion and participants’ knowledge about advance directives as well as physician-assisted dying and euthanasia were each rated on a 5-point Likert-type scale (for the degree of importance, 1 = low importance and 5 = very important; for the degree of knowledge, 1 = not knowledgeable and 5 = very knowledgeable), while the degree of importance of political standing was measured using a 3-point scale (1 = weak and 3 = strong).

Participants chose one of the four distinct advance directives randomly: All four forms were placed in front of the participant without any information that each questionnaire was distinct and different from the others. Researchers tried to design the whole process so as not to influence each participant’s choice.

This study was approved by the institutional review board of Dongguk Institute, and all subjects gave informed consent to participate in the study.

Statistical Analysis

All statistical tests were interpreted as significant at the 5% level (two-sided for among group comparisons of study outcomes). All outputs were produced using SPSS, Version 20 (SPSS Inc., Chicago, IL). Continuous data were summarized by group and overall by number of observations, mean value, standard deviation, odds ratio, slope, and 95% confidence intervals for the mean. Categorical data were summarized by means of frequencies (counts and percentages) per group. One-way analyses of variance with post hoc tests (with Bonferroni correction) were used to test differences among groups. The data were analyzed by Student’s t test for two-group comparisons. All categorical data were analyzed using Pearson’s χ² test and binomial test.

Results

Sample Characteristics

One hundred and eighty-five subjects, with a mean age of 47 years, participated in the study (Table 2). Over half of the participants were women (n = 101, 54.6%). One hundred and seventy participants identified as religious, with most following Buddhism (n = 128, 69.2%). Participants with an identified religion engaged in various religious activities at least once a month and answered that their faith and religious teachings were important when they made a decision (3.47 ± 1.55 [mean ± standard deviation]). Participants were also relatively politically conservative, with 41.6% identifying as conservative, 35.1% as moderate, and 22.2% as liberal. Regarding the importance of their political attitudes, there was no significant difference between conservatives and liberals (1.64 ± 0.69 vs. 1.43 ± 0.55). Most participants responded that they were well-informed about euthanasia (4.82 ± 1.19). In terms of advance directives and physician-assisted dying, the degree of prior knowledge was far lower than that for euthanasia (2.94 ± 1.68 and 2.85 ± 1.78, respectively).

Table 2.

Demographic Characteristics (Total Participants, n = 185).

	Mean ± SD or n (%)
Age (years)	47.5 ± 12.42
Gender
Male	62 (33.5)
Female	101 (54.6)
Religion	170 (91.9)
Degree of importance^a	3.47 ± 1.55
Religious activities (per month)	>1 (per month)
Political trait
Conservative	77 (41.6)
Liberal	41 (22.2)
Moderate	65 (35.1)
How strong^b
Conservative	1.64 ± 0.69
Liberal	1.43 ± 0.55
Prior knowledge^c
Advance directives	2.94 ± 1.68
Physician-assisted dying	2.85 ± 1.78
euthanasia	4.82 ± 1.19

Note. SD = standard deviation.

^aDegree of importance from 1 (low importance) to 5 (very important). ^bDegree of political convictions from 1 (weak) to 3 (strong). ^cDegree of prior knowledge from 1 (not knowledgeable) to 5 (very knowledgeable).

Responses to Life-Sustaining Treatments by Advance Directives

Table 3 outlines participants’ responses to the four distinct forms. Participants’ responses to each form were significantly different in relation to their decisions regarding special life-sustaining treatments. Between 60% and 70% of participants chose to “accept the interventions” on the reference form. However, the majority of participants (70%–90%) chose “refuse the intervention” on the negative form. On the religious form, 70% to 80% chose “not decided yet.” On the combined form, responses to CPR and ventilator care were similar to those on the negative form. However, the effect of negative content was not significant for other options such as dialysis and inotropics.

Table 3.

The Responses to Four Distinctive Forms of Advance Directive.

	AD form	Accept	Refuse	Not decided yet	p value
Special life-sustaining treatments
CPR	Reference	22 (50)	7 (15)	6 (35)	.000
	Negative	11 (14)	69 (85)	1 (1)
	Religious	4 (15)	2 (7)	21 (78)
	Combined	4 (14)	21 (72)	4 (14)
Ventilator	Reference	22 (50)	7 (15)	6 (35)	.000
	Negative	11 (14)	69 (85)	1 (1)
	Religious	4 (10)	2 (10)	21 (80)
	Combined	4 (14)	21 (72)	4 (14)
Dialysis	Reference	25 (66)	8 (21)	5 (13)	.000
	Negative	21 (26)	59 (73)	1 (1)
	Religious	7 (26)	1 (4)	19 (70)
	Combined	7 (23)	13 (43)	10 (34)
Transfusion	Reference	28 (74)	4 (10)	6 (16)	.000
	Negative	26 (32)	55 (68)	0 (0)
	Religious	9 (33)	0 (0)	18 (67)
	Combined	12 (40)	10 (30)	8 (30)
Chemotherapy	Reference	25 (66)	5 (13)	8 (21)	.000
	Negative	22 (27)	59 (73)	0 (0)
	Religious	6 (21)	0 (0)	21 (79)
	Combined	5 (16)	11 (37)	14 (47)
Antibiotics	Reference	26 (68)	4 (11)	8 (21)	.000
	Negative	31 (38)	50 (62)	0 (0)
	Religious	9 (33)	0 (0)	18 (67)
	Combined	14 (47)	10 (33)	6 (20)
Inotropics	Reference	26 (68)	4 (11)	8 (21)	.000
	Negative	24 (30)	57 (70)	0 (0)
	Religious	8 (30)	0 (0)	19 (70)
	Combined	8 (27)	12 (40)	10 (33)
General life-sustaining treatments
Nutrition and hydration	Reference	33 (87)	4 (10)	1 (3)	.000
	Negative	45 (56)	35 (44)	0 (0)
	Religious	16 (60)	0 (0)	11 (40)
	Combined	23 (77)	1 (3)	6 (20)
O₂ supply	Reference	33 (87)	4 (10)	1 (3)	.000
		Negative	45 (56)	35 (44)	0 (0)
		Religious	17 (63)	0 (0)	10 (37)
		Combined	23 (77)	1 (3)	6 (20)
Voiding and defecation	Reference	30 (79)	6 (16)	2 (5)	.000
	Negative	45 (56)	35 (44)	0 (0)
	Religious	18 (67)	0 (0)	9 (33)
	Combined	22 (73)	3 (10)	5 (27)
Sore care	Reference	32 (84)	4 (11)	2 (5)	.000
	Negative	49 (61)	31 (39)	0 (0)
	Religious	18 (67)	0 (0)	9 (33)
	Combined	23 (77)	2 (7)	5 (16)
Pain control	Reference	33 (87)	4 (11)	1 (2)	.000
	Negative	55 (69)	25 (31)	0 (0)
	Religious	19 (73)	0 (0)	7 (27)
	Combined	24 (80)	2 (7)	4 (13)
Counseling
Psychological counseling	Reference	30 (79)	6 (16)	2 (5)	.000
	Negative	58 (74)	20 (26)	0 (0)
	Religious	19 (70)	0 (0)	8 (30)
	Combined	22 (76)	2 (7)	5 (17)
Spiritual or religious counseling	Reference	22 (56)	13 (33)	4 (11)	.000
	Negative	60 (75)	20 (25)	0 (0)
	Religious	18 (67)	0 (0)	9 (33)
	Combined	19 (63)	7 (23)	4 (14)

Note. Data are expressed as n (%). p values are derived from χ² tests. AD = advance directive; CPR = cardiopulmonary resuscitation.

In terms of general life-sustaining treatments, most participants expressed a preference for all interventions across the forms. The forms containing negative or religious content affected decision-making similarly, but the effects were not marked.

Regarding preferences for psychological and spiritual or religious counseling, response trends were similar to those for general life-sustaining treatments. More than 70% of participants expressed a preference for counseling. Negative or religious content had much less influence on preferences for counseling compared to its effect on preferences for special life-sustaining treatments.

We observed some important demographic differences related to decisions about life-sustaining treatments. In terms of choices related to special life-sustaining treatments, there was a marked significant difference between men and women (Table 4). Women were more likely to refuse treatment than men. Similarly, even though both men and women preferred to accept general life-sustaining interventions, a trend was identified whereby men were more accepting of treatment than women.

Table 4.

The Effect of Gender on Decision-Making Related to Life-Sustaining Treatments in Advance Directive.

		Accept	Refuse	Not decided yet	p value
Special life-sustaining treatments
CPR	M	30 (51)	20 (34)	9 (15)	.000
CPR	F	18 (19)	57 (59)	22 (22)
Ventilator	M	25 (43)	24 (41)	9 (16)	.000
Ventilator	F	13 (14)	65 (68)	18 (18)
Dialysis	M	30 (50)	23 (44)	7 (16)	.002
Dialysis	F	23 (23)	53 (54)	22 (23)
Transfusion	M	35 (58)	17 (28)	8 (14)	.003
Transfusion	F	30 (30)	49 (50)	19 (20)
Chemotherapy	M	26 (43)	23 (38)	11 (18)	.092
Chemotherapy	F	26 (27)	48 (49)	24 (24)
Antibiotics	M	36 (60)	17 (28)	7 (12)	.034
Antibiotics	F	38(39)	43 (44)	17 (17)
Inotropics	M	34 (57)	18 (30)	8 (13)	.001
Inotropics	F	27 (28)	50 (51)	21 (21)
General life-sustaining treatments
Nutrition and hydration	M	49 (80)	9 (15)	3 (5)	.016
Nutrition and hydration	F	56 (58)	27 (28)	13 (14)
O₂ supply	M	49 (80)	9 (15)	3 (5)	.014
O₂ supply	F	55 (58)	28 (29)	12 (13)
Voiding and defecation	M	47 (78)	9 (15)	4 (7)	.025
Voiding and defecation	F	55 (57)	31 (32)	10 (10)
Sore care	M	50 (83)	7 (12)	3 (5)	.015
Sore care	F	59 (61)	27 (28)	10 (10)
Pain control	M	52 (85)	6 (10)	3 (5)	.091
Pain control	F	66 (70)	21 (22)	7 (7)
Counseling
Psychological counseling	M	45 (75)	11 (18)	4 (7)	.705
Psychological counseling	F	74 (78)	13 (14)	8 (8)
Spiritual or religious counseling	M	35 (57)	20 (33)	6 (10)	.049
Spiritual or religious counseling	F	72 (75)	16 (17)	8 (8)

Note. Data are expressed as n (%). p values are derived from χ² tests. CPR = cardiopulmonary resuscitation; M = male; F = female.

Participants who refused special life-sustaining treatment were older, with better prior knowledge about advance directives and end-of-life care (Table 5). Participants who refused general life-sustaining treatment were older. In terms of counseling, none of the factors tested affected the decision whether to accept psychological counseling. However, participants who accepted spiritual or religious counseling showed distinct characteristics: They depended more on religion to make decisions and knew more about advance directives. Interestingly, compared with younger participants, older participants were more likely to refuse life-sustaining interventions but preferred spiritual or religious counseling.

Table 5.

The Effect of Age on Decision-Making Related to life-Sustaining Treatments in Advance Directives.

	Accept	Refuse	Not decided yet	p value	Multiple comparison (Bonferroni correction)
Special life-sustaining treatments
CPR	41.13 ± 13.09	51.50 ± 9.40	46.24 ± 13.00	.000	1 ≠ 2
Ventilator	35.98 ± 11.52	51.81 ± 9.38	47.66 ± 12.02	.000	1 ≠ 2, 1 ≠ 3
Dialysis	42.22 ± 13.57	50.95 ± 10.63	48.20 ± 10.53	.000	1 ≠ 2
Transfusion	41.61 ± 12.98	52.64 ± 9.76	49.89 ± 9.46	.000	1 ≠ 2, 1 ≠ 3
Chemotherapy	42.55 ± 12.86	51.72 ± 10.44	46.34 ± 12.18	.000	1 ≠ 2
Antibiotics	41.89 ± 12.60	53.80 ± 8.710	48.64 ± 11.42	.000	1 ≠ 2, 1 ≠ 3
Inotropics	41.26 ± 12.92	52.66 ± 9.63	48.25 ± 10.94	.000	1 ≠ 2, 1 ≠ 3
General life-sustaining treatments
Nutrition and hydration	44.59 ± 13.19	51.87 ± 7.68	54.67 ± 9.66	.000	1 ≠ 2, 1 ≠ 3
O₂ supply	44.82 ± 13.44	51.85 ± 7.58	53.59 ± 9.23	.001	1 ≠ 2, 1 ≠ 3
Voiding and defecation	45.18 ± 13.28	51.79 ± 8.87	51.00 ± 10.97	.006	1 ≠ 2
Sore care	45.28 ± 13.28	51.92 ± 7.95	53.00 ± 9.95	.003	1 ≠ 2
Pain control	45.73 ± 13.04	51.48 ± 8.45	54.33 ± 9.88	.010	1 ≠ 2, 1 ≠ 3
Counseling
Psychological counseling	46.54 ± 12.36	49.00 ± 12.38	49.33 ± 12.98	.508
Spiritual or religious counseling	48.98 ± 11.61	42.72 ± 13.36	47.65 ± 13.06	.024	1 ≠ 2

Note. Data are expressed as mean ± standard deviation years old. p values are derived from one-way analysis of variances. CPR = cardiopulmonary resuscitation.

Discussion

Recently, the act on decisions on life-sustaining treatment for patients in hospice and palliative care or at the end of life, which addresses advance directives and advance care planning, was legislated in Korea and has taken effect since February 4^th, 2018. This act is anticipated to provide a legal basis for various forms of end-of-life care and promote a patient’s autonomy and right to make decisions. However, the decision-making process is complex and easily influenced by intrinsic and extrinsic factors (Hash, Bodnar-Deren, Leventhal, & Leventhal, 2016). Moreover, a recent article showed that many patients misinterpret the goal of interventions. The framing effect is one of the most powerful factors affecting a patient’s decision-making (H. R. Lee, Lim, Yun, Kang, & Kim, 2018). Although the framing effect has been studied in various medical situations, the effect of the word(s) and content in advance directives on individual’s decision-making has not been thoroughly evaluated. Malloy, Wigton, Meeske, and Tape (1992) evaluated three separate hypothetical scenarios related to decisions about CPR, mechanical ventilation, and tube feeding in 201 community-dwelling elderly participants. One of the three case scenarios served as a reference and the remaining two were described in a positive or negative way. Participants chose the intervention 12% of the time in the negative scenario, 18% of the time in the reference scenario, and 30% of the time in the positive scenario. Seventy-seven percent of the participants changed their minds more than once when they encountered different scenarios with the same intervention. Our study showed similar results: Participants did not accept special life-sustaining treatments when they encountered the negative form of scenarios.

This study also evaluated religious content in advance directives, and our results demonstrated that participants were undecided with respect to special life-sustaining treatments, although less so when deciding on general interventions. It is likely that religious teachings make people more likely to defer their judgments of whether to accept or refuse a life-sustaining treatment. Religious concerns should be addressed more carefully in advance care planning because it is possible that religious practices limit the range and flexibility of options and choices by restricting the authority of an agent, which may lead to confusion and controversy (Grodin, 1993). Moreover, the interaction between negative content and religious teaching content is very complex; further study is needed to evaluate the exact role of advanced directives framed in religious terms in real clinical settings.

Prior knowledge regarding advance directives meaningfully influenced decision-making related to CPR and ventilator care. The more knowledgeable the participants were, the more likely they were to refuse interventions. However, no relationships were observed with respect to prior knowledge of physician-assisted suicide and euthanasia. Although there are several reports that political preferences can affect personal decisions and behavior (Haidt, Graham, & Joseph, 2009; Hannikainen, Miller, & Cushman, 2017), we did not find any significant effects of political traits on decision-making. It is also interesting that gender exerted a significant influence upon decision-making about life-sustaining treatments. Attitudes about advance care planning differed according to gender (Perkins, Cortez, & Hazuda, 2004); men considered only functional outcome regarding their end-of-life wishes and feared harm from the health system. Women felt empowered by the system and expressed various end-of-life wishes. More attention should be paid to avoid biased traditional gender roles and social prejudice for proper advance care planning. One of the important methods to overcome the effect of these factors would be continuous and extensive education about advance directives.

There are various ways in which content influences the final decision. One is that the content of advance directives could directly affect decision-making. Another is that there might be a mediator(s) that links content and final decision. For example, the wording of information can provoke tremendous emotional weight (Peppin, 1995), which can affect the individual’s ability to make sound and reasonable decisions. However, as Seo and Barrett (2007) demonstrated, individuals with superior decision-making performance are better able to identify and distinguish their current emotional state. Thus, the effect of emotion may depend upon how it is experienced, managed, and used in decision-making processes. According to dual-process theory, reasoning is involved in utilitarian moral judgments, but affective processes are important in deontological moral judgments (Horne & Powell, 2016). Despite controversy regarding the role of emotion in moral dilemmas, and the weak link between emotional responses and moral judgments, it is evident that emotions can be a source of bias (Gross & John, 2003) or a key player in decision-making (Slovic, Finucane, Peters, & MacGregor, 2007). Emotions can motivate morally relevant actions (Greene & Haidt, 2002; Preston & de Waal, 2002) and lead to moralization (Haidt, 2001). According to our results, it is possible that the specific content of each advance directive provoked different emotional responses from the participants. Further study will be needed to evaluate the role of emotion in decision-making related to advance directives.

There are several limitations to this study. First, the length and readability of the four distinct forms of advance directive were not comparable. Mazur and Hickam (1990) reported that even when framing influences are controlled, preferences can be affected by other attributes of summary data, namely, the amount of data presented. However, in this study, there were no significant differences with regard to accuracy, clarity, and completeness of the descriptions in the questionnaire. Second, racial and ethnic differences are well-documented in advance care planning (McAfee, Jordan, Sheu, Dake, & Kopp Miller, 2019; Nayfe, Marcoux & Jutai, 2019), even though there may be stark differences in marital, parental, educational, and socioeconomic status among members of a racial group. Carr (2012) reported that Asians are 58% less likely than Whites to have end-of-life discussions, but the former are 56% more likely to have living wills than the latter. Asians show tendencies to rely on formal documents and do not want to engage in discussions about dying (S. K. Lee, 2009). Further study would be needed to extrapolate the results to other ethnic groups and evaluate which ethnic groups are more likely to be affected by the content of advance directives. Third, as participants in our research were presented with hypothetical scenarios, it is plausible that their preferences could be different if they were confronted with real-life situations or if they faced terminal illness. Finally, the study showed that religiously framed advance directives influenced decision-making about end-of-life care. Individuals who consider themselves religious exhibit particular attitudes toward death (Lynn, Curtis, & Lagerwey, 2015). Most participants in this study were Buddhists. Therefore, it was difficult to determine whether responses to life-sustaining interventions and attitudes toward death varied according to individuals’ faith backgrounds.

It is important for free and informed consent to assess the content of advance directives and develop strategies to discourage the use of potentially persuasive language. First, advance directives should be written in a neutral manner, without using value-laden words such as pain, burden, and futile, because these words might evoke an emotional response or a negative assessment of quality of life. Second, as advance directives have psychosocial and legal implications in addition to medical implications, experts across disciplines, including health-care professionals, lawyers, social workers, and psychologists, should work together to create neutrally framed advance directives. Finally, as advance directives do not operate in isolation from care planning discussions, physicians or health-care personnel should discuss end-of-life care with patients in a manner that is neither biased nor prejudiced.

Conclusions

It is clear that the specific content of advance directives can affect decision-making with regard to various medical interventions related to end-of-life care. More attention should be paid to understand the effect of the content of advance directives and to facilitate the appropriate and autonomous decision-making related to end-of-life care.

Footnotes

Acknowledgments

The authors would like to express their sincerest thanks and appreciation to Matthew Bro for his valuable support and flawless grammatical editing of this article.

Declaration of Conflicting Interests

The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Dongguk University, but it had no role in protocol design, collection or analysis of the data, or interpretation or writing of the results.

Author Biographies

Jae Yoon Park, MD, is an assistant professor in the Department of Internal Medicine at Dongguk University Ilsan Hospital. As a nephrologist, his research interests include acute kidney injury, gerontology, and translational research. Park teaches general nephrology at the Dongguk University College of Medicine.

Chi-Yeon Lim, PhD, is an associate professor of medical school of Dongguk University in Republic of Korea. She obtained her PhD from Pusan University in Biostatistics. Through over 20-year work experience in biostatistics including 7 years of experience in pharmaceutical industry, She gained extensive and diversified knowledge and experience in overall drug development process and management of clinical data in clinical research.

Gloria Puurveen, PhD, is a postdoctoral researcher at the W. Maurice Young Centre for Applied Ethics at the University of British Columbia. Her research interests centres on end-of-life person-centred dementia care, advance care planning, and living well with dementia to the end of life. She primarily uses qualitative and arts-based research methodologies and seeks to cultivate ethical research practice through collaborating with people with dementia and their care partners through the entire research process.

Do Yeun Kim, MD, PhD, MPH, is a professor of hematology and medical oncology of Dongguk University Ilsan Hospital. She also serves as an assistant administrator of insurance and policy division of Korean Society of Medical Oncology and a member of research division of Korean Society for Hospice and Palliative Medicine. Her research interests include quality of care for cancer patients, evidence-based patient-centered decision-making, end of life planning, and health policy for better cancer care.

Jae Hang Lee, MD, is an associate professor of Dongguk University Ilsan Hospital and a chief surgeon in the Department of Thoracic and Cardiovascular Surgery. He also serves as an academic director in the Korean Society of Vascular and Endovascular Surgery and worked as a vice-chief at an International Medical Center for patients in the underdeveloped countries. He currently teaches a critical care medicine, and his main concern is about the quality of life and ethics for the critically ill patients.

Han Ho Do, MD, PhD, is an associate professor of Dongguk University College of Medicine. He also serves as an educational director of Society of Emergency and Critical Care Imaging. His teaching and research interests include physician training, point of care ultrasound, and end of life planning. He obtained his PhD from the University of Dongguk in Preventive Medicine, where he focused on research about Injury Prevention and Advance Health Care Directive.

Kyung Soo Kim, MD, PhD, is a professor of division of nephrology at Dongguk University Medical School. He also serves as clinical at Dongguk University Ilsan Hospital. He takes care of patients with end stage renal disease on hemodialysis, peritoneal dialysis, or kidney transplantation. His teaching and research interests include survivorship in end stage renal disease, prevention of chronic kidney disease progression, and kidney transplantation immunology.

Kyung Don Yoo, MD, PhD, is an assistant professor in the Department of Internal Medicine at the Dongguk University College of Medicine. He currently works as a medical director of nephrology and dialysis at Dongguk University Gyeongju Hospital. He obtained his PhD in biomedical science from the Seoul National University, where he focused on translational research for the patients with kidney disease.

Hyo Jin Kim, MD, is an assistant professor in the department of internal medicine at the Dongguk University College of Medicine. She currently teaches medical students at the Dongguk University College of Medicine. She currently works as a nephrologist at Dongguk University Gyeongju Hospital. She is interested in chronic kidney disease and dialysis. She is a member of the KNOW-CKD (KoreaN cohort study for Outcome in patients With Chronic Kidney Disease) cohort and is a co-author in the “The Essentials of Clinical Dialysis”.

Yunmi Kim, MD, is a clinical assistant professor in the department of internal medicine, Dongguk University Gyeongju Hospital. She is doing clinical practice as a nephrologist at Dongguk University Gyeongju Hospital. She also teaches medical students at the Dongguk University College of Medicine.

Sung Joon Shin, MD, PhD, is a professor in the department of internal medicine of Dongguk University Hospital in South Korea. He also serves as a director of Medical Ethics Committee at Dongguk University Hospital and co-chair of Ethics Committee of the Korean Society of Nephrology. His general areas of research interests and experience are in critical care and clinical nephrology. He is also interested in understanding medical ethics in cultural and religious contexts as well as developing a new curriculum that can tackle current ethical challenges in South Korea: end of life care, advance care plan, physician-assisted death, transplantation, health policy, and resource allocation.

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