A Trial of Expanded Choice Sets in Advance Directives for Hemodialysis Patients

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 DESCRIPTION (provided by applicant): There is a large gap between the care patients with end-stage renal disease on maintenance hemodialysis (ESRD-HD) want and the care they receive near the end-of-life. Unfortunately, hemodialysis patients experience frequent hospitalizations and aggressive medical care near the end of life despite a preference for comfort-focused care if they are seriously ill. This, in part, is explained by historically unsatisfactory advance care planning including low rates of advance directive completion in this population. Timely engagement in advance care planning is particularly important for ESRD-HD patients who have a median five-year survival shorter than many patients with cancer and have a distinctly rapid functional decline in the final month of life. Advance directives offer an opportunity for patients to express specific end-of-life preferences to avoid unwanted care. As promising as advance directives may be for improving the quality of care near the end of life, rates of completion remain low and previous efforts to encourage their completion have had limited success. Moreover, among patients who do complete an advance directive, one in four do not provide sufficient guidance in it for surrogate decision makers to provide care consistent with their goals and values. Principles of behavioral economics, such as decision framing effects, may offer a novel approach to address previous shortcomings in advance directive implementation and bridge the gap in end-of-life care. For example, targeting patients with identifiable risk factors for critical illness or death in the foreseeable future increases the probability that patients' stated preferences will still apply when the advance directive is needed The goal of this study is to test whether changing the context of decisions regarding advance directive completion can increase the probability that hemodialysis patients will complete, and specify actionable choices within, advance directives. First, we aim to determine if expanding the choices for completing an advance directive by offering different versions of them will increase the proportion of patients who complete one. Second, we aim to determine if expanding the range of choices for receipt or not of life-supportive therapies within an advance directive will decrease the proportion of patients who do not specify any preference. This project will provide essential preliminary data for a planned NIH K23 Career Development Award that would (1) examine more definitively how this and other decision nudges influence ESRD-HD patients' decisions, (2) compare longitudinal patient-reported quality of life, functional status, and healthcare utilization patterns near the end of life among ESRD-HD patients who do or do not complete advance directives, and (3) compare other behavioral economic interventions for improving advance directive completion among a larger population of patients receiving maintenance hemodialysis therapy.