Advance care planning (ACP), the process by which individuals can prepare for future treatment decisions, remains underutilized. ACP addresses many of the issues that patients and caregivers endorse as important in end-of-life care; however, there are many emotional, cognitive, and practical barriers to engagement. While a patient-centered interviewing approach has been demonstrated to enhance engagement, such intensive interventions may be best suited for patients with serious chronic illness. The Institute of Medicine has endorsed a lifespan approach to ACP, with earlier engagement among patients in good health. This project takes a public health approach to promote ACP engagement among a broad cross-section of Veterans.
The objective of this project is to examine the effects of two theory-based behavioral interventions (computer-tailored feedback [CTI] based on the Trans-Theoretical Model and motivational interviewing [MI]) alone and in combination on completion of four key ACP behaviors: selecting a health care proxy, communicating with the proxy about goals of care, documentation of proxy selection and goals, and entry of documents into the electronic medical record).
Single-blind randomized controlled trial with four arms: usual care, CTI, MI, and CTI+MI, otherwise known as MET (motivational enhancement therapy). Participants will be Veterans age 55 years and older receiving primary care at VA Connecticut Healthcare System. All participants will receive a baseline assessment, examining their readiness to engage in each of the ACP behaviors, attitudes toward pros and cons of engagement, values and beliefs regarding ACP, and processes for behavior change. Based on this assessment, participants in the CTI group will receive a detailed personalized feedback report and a stage-matched brochure providing additional information about ACP. Participants in the MI group will receive a brief session with a trained counselor to strengthen commitment to engage in ACP and enhance self-efficacy. These interventions will be repeated at two and four months. The primary outcome, measured at six months, is completion of all 4 ACP behaviors.
A total of 248 Veterans have been contacted by telephone. Of these, 22 were unable to be reached. Of the remaining 226, 99 refused telephone screening, and 48 were found to be ineligible, most often (42/48) because they had completed all 4 ACP behaviors. Thus, to date, 79 Veterans were consented for study participation, with 1 subsequently declining to complete the baseline assessment. Of the 78 Veterans enrolled and randomized, there are 21 in the control arm, 18 in the CTI arm, 19 in the MI arm, and 20 in the MET arm. With the use of block randomization, the number of ACP behaviors completed are distributed equally across the study arms.
If demonstrated to be efficacious, the interventions being tested in this proposal will have been shown to increase engagement in ACP, which has been identified as a key component of high-quality end-of-life care. This project takes the important step of introducing ACP into the primary care of Veterans, conceptualizing ACP as a component of the well visit and promoting engagement with interventions that hold the potential for widespread dissemination at modest cost.
As a first step in demonstrating impact, we have a manuscript in press detailing the feasibility of motivational interviewing (MI) for ACP. We have a full manual and rating system available upon request for interested clinicians in order to promote dissemination of the MI protocol.
- Fried TR, Redding CA, Martino S, Paiva A, Iannone L, Zenoni M, Blakley LA, Rossi JS, O'Leary J. Increasing engagement in advance care planning using a behaviour change model: study protocol for the STAMP randomised controlled trials. BMJ open. 2018 Aug 10; 8(8):e025340.
- Fried TR, Leung SL, Blakley LA, Martino S. Development and Pilot Testing of a Motivational Interview for Engagement in Advance Care Planning. [Letter to the Editor]. Journal of palliative medicine. 2018 Jul 1; 21(7):897-898.