Despite the substantial personal and economic implications of end-of-life decisions, many individuals fail to document their wishes, which often leads to patient dissatisfaction and unnecessary medical spending. We conducted a randomized trial of 1,200 patients aged 55 years and older to facilitate advance directive (AD) completion and better understand why patients fail to engage in high-value planning. We found that including a physical AD form with paper letters as a nudge to decrease hassle costs increased AD completion by 9.0 percentage points (95% confidence interval [CI] = [4.2, 13.9] percentage points). The intervention was especially effective for individuals aged 70 years and older, as AD completion increased by 17.5 percentage points (95% CI = [5.7, 9.4] percentage points). When compared with the impact of costless electronic reminders, each additional AD completion from the letter interventions costs as little as US$37. Our findings suggest that simple, inexpensive interventions with paper communication as behavioral nudges can be effective, especially in older populations.
AldridgeM. D.KelleyA. S. (2015). The myth regarding the high cost of end-of-life care. American Journal of Public Health, 105(12), 2411–2415. https://doi.org/10.2105/AJPH.2015.302889
2.
AndersonL. A.GoodmanR. A.HoltzmanD.PosnerS. F.NorthridgeM. E. (2012). Aging in the United States: Opportunities and challenges for public health. American Journal of Public Health, 102(3), 393–395. https://doi.org/10.2105/AJPH.2011.300617
3.
AuriemmaC. L.HalpernS. D.AschJ. M.Van Der TuynM.AschD. A. (2020). Completion of advance directives and documented care preferences during the coronavirus disease 2019 (COVID-19) pandemic. JAMA Network Open, 3(7), Article e2015762. https://doi.org/10.1001/jamanetworkopen.2020.15762
4.
BakerR.HygM.WuA. W.TenoJ. M.KrelingB.DamianoA. M.RubinH. R.RoachM. J.WengerN. S.PhillipsR. S.DesbiensN. A.Connors JrA. F.KnausW.LynnJ. (2000). Family satisfaction with end-of-life care in seriously ill hospitalized adults. Journal of the American Geriatrics Society, 48(S1), S61–S69. https://doi.org/10.1111/j.1532-5415.2000.tb03143.x
5.
BischoffK. E.SudoreR.MiaoY.BoscardinW. J.SmithA. K. (2013). Advance care planning and the quality of end-of-life care in older adults. Journal of the American Geriatrics Society, 61(2), 209–214. https://doi.org/10.1111/jgs.12105
6.
Brinkman-StoppelenburgA.RietjensJ. A.van der HeideA. (2014). The effects of advance care planning on end-of-life care: A systematic review. Palliative Medicine, 28(8), 1000–1025. https://doi.org/10.1177/0269216314526272
7.
ChambersC. V.DiamondJ. J.PerkelR. L.LaschL. A. (1994). Relationship of advance directives to hospital charges in a Medicare population. Archives of Internal Medicine, 154(5), 541–547. https://doi.org/10.1001/archinte.1994.00420050093009
8.
CourtrightK. R.MaddenV.GablerN. B.CooneyE.KimJ.HerbstN.BurgoonL.WhealdonJ.DemberL. M.HalpernS. D. (2017). A randomized trial of expanding choice sets to motivate advance directive completion. Medical Decision Making, 37(5), 544–554. https://doi.org/10.1177/0272989X16663709
DeteringK. M.HancockA. D.ReadeM. C.SilvesterW. (2010). The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ, 340, Article c1345. https://doi.org/10.1136/bmj.c1345
12.
DexterP. R.WolinskyF. D.GramelspacherG. P.ZhouX.-H.EckertG. J.WaisburdM.TierneyW. M. (1998). Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms. Annals of Internal Medicine, 128(2), 102–110. https://doi.org/10.7326/0003-4819-128-2-199801150-00005
13.
DixonJ.MatosevicT.KnappM. (2015). The economic evidence for advance care planning: Systematic review of evidence. Palliative Medicine, 29(10), 869–884. https://doi.org/10.1177/0269216315586659
EmanuelE. J.EmanuelL. L. (1994). The economics of dying—The illusion of cost savings at the end of life. New England Journal of Medicine, 330(8), 540–544. https://doi.org/10.1056/NEJM199402243300806
16.
FrenchE. B.McCauleyJ.AragonM.BakxP.ChalkleyM.ChenS. H.ChristensenB. J.ChuangH.Côté-SergentA.De NardiM.FanE.ÉchevinD.GeoffardP.-Y.Gastaldi-MénagerC.GørtzM.IbukaY.JonesJ. B.Kallestrup-LambM.KarlssonM.. . .KellyE. (2017). End-of-life medical spending in last twelve months of life is lower than previously reported. Health Affairs, 36(7), 1211–1217. https://doi.org/10.1377/hlthaff.2017.0174
17.
GarridoM. M.HarringtonS. T.PrigersonH. G. (2014). End-of-life treatment preferences: A key to reducing ethnic/racial disparities in advance care planning?Cancer, 120(24), 3981–3986. https://doi.org/10.1002/cncr.28970
18.
HaisleyE.VolppK. G.PellathyT.LoewensteinG. (2012). The impact of alternative incentive schemes on completion of health risk assessments. American Journal of Health Promotion, 26(3), 184–188. https://doi.org/10.4278/ajhp.100729-ARB-257
19.
HalpernS. D.LoewensteinG.VolppK. G.CooneyE.VranasK.QuillC. M.McKenzieM. S.HarhayM. O.GablerN. B.SilvaT.ArnoldR.AngusD. C.BryceC. (2013). Default options in advance directives influence how patients set goals for end-of-life care. Health Affairs, 32(2), 408–417. https://doi.org/10.1377/hlthaff.2012.0895
20.
HarlowK. (2017). An educational intervention to increase advance directive completion (S706). Journal of Pain and Symptom Management, 53(2), 412–413. https://doi.org/10.1016/j.jpainsymman.2016.12.216
21.
HigginsonI. J.Sen-GuptaG. J. A. (2000). Place of care in advanced cancer: A qualitative systematic literature review of patient preferences. Journal of Palliative Medicine, 3(3), 287–300. https://doi.org/10.1089/jpm.2000.3.287
22.
HoganC.LunneyJ.GabelJ.LynnJ. (2001). Medicare beneficiaries’ costs of care in the last year of life. Health Affairs, 20(4), 188–195. https://doi.org/10.1377/hlthaff.20.4.188
23.
HorvathM.LevyJ.L’EngleP.CarlsonB.AhmadA.FerrantiJ. (2011). Impact of health portal enrollment with email reminders on adherence to clinic appointments: A pilot study. Journal of Medical Internet Research, 13(2), Article e1702. https://doi.org/10.2196/jmir.1702
24.
HviidM.ShafferG. (1999). Hassle costs: The Achilles’ heel of price-matching guarantees. Journal of Economics & Management Strategy, 8(4), 489–521. https://doi.org/10.1111/j.1430-9134.1999.00489.x
JimenezG.TanW. S.VirkA. K.LowC. K.CarJ.HoA. H. Y. (2018). Overview of systematic reviews of advance care planning: Summary of evidence and global lessons. Journal of Pain and Symptom Management, 56(3), 436–459.e25. https://doi.org/10.1016/j.jpainsymman.2018.05.016
27.
JosephsM.BayardD.GablerN. B.CooneyE.HalpernS. D. (2018). Active choice intervention increases advance directive completion: A randomized trial. MDM Policy & Practice, 3(1), 1–9. https://doi.org/10.1177/2381468317753127
28.
KimmelS. E.TroxelA. B.LoewensteinG.BrensingerC. M.JaskowiakJ.DoshiJ. A.LaskinM.VolppK. (2012). Randomized trial of lottery-based incentives to improve warfarin adherence. American Heart Journal, 164(2), 268–274. https://doi.org/10.1016/j.ahj.2012.05.005
29.
LambrechtA.TuckerC. (2011). Paying with money or with effort: Pricing when customers anticipate hassle. SSRN Electronic Journal. Advance online publication. https://doi.org/10.2139/ssrn.1805109
30.
MaciosekM. V.LaFranceA. B.DehmerS. P.McGreeD. A.FlottemeschT. J.XuZ.SolbergL. I. (2017). Updated priorities among effective clinical preventive services. The Annals of Family Medicine, 15(1), 14–22. https://doi.org/10.1370/afm.2017
31.
MarshallG. (2015). Hassle costs and price discrimination: An empirical welfare analysis. American Economic Journal: Applied Economics, 7(3), 123–146.
32.
MarshallS.McGarryK. M.SkinnerJ. S. (2010). Working paper series: The risk of out-of-pocket health care expenditure at end of life (Working Paper No. 16170). National Bureau of Economic Research. https://doi.org/10.3386/w16170
33.
McMahanR. D.TellezI.SudoreR. L. (2021). Deconstructing the complexities of advance care planning outcomes: What do we know and where do we go? A scoping review. Journal of the American Geriatrics Society, 69(1), 234–244. https://doi.org/10.1111/jgs.16801
MolloyD. W.GuyattG. H.RussoR.GoereeR.O’BrienB. J.BédardM.WillanA.WatsonJ.PattersonC.HarrisonC.StandishT.StrangD.DarzinsP. J.SmithS.DuboisS. (2000). Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial. JAMA, 283(11), 1437–1444. https://doi.org/10.1001/jama.283.11.1437
NicholasL. H.LangaK. M.IwashynaT. J.WeirD. R. (2011). Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA, 306(13), 1447–1453. https://doi.org/10.1001/jama.2011.1410
40.
PatelM. S.MilkmanK. L.GandhiL.GraciH. N.GrometD.HoH.KayJ. S.LeeT. W.RothschildJ.AkinolaM.BeshearsJ.BogardJ. E.ButtenheimA.ChabrisC.ChapmanG. B.ChoiJ. J.DaiH.FoxC. R.GorenA.. . .DuckworthA. L. (2023). A randomized trial of behavioral nudges delivered through text messages to increase influenza vaccination among patients with an upcoming primary care visit. American Journal of Health Promotion, 37(3), 324–332. https://doi.org/10.1177/08901171221131021
PrendergastT. J. (2001). Advance care planning: Pitfalls, progress, promise. Critical Care Medicine, 29(2), N34–N39.
43.
RaoJ. K.AndersonL. A.LinF.-C.LauxJ. P. (2014). Completion of advance directives among U.S. consumers. American Journal of Preventive Medicine, 46(1), 65–70. https://doi.org/10.1016/j.amepre.2013.09.008
44.
ResnickH. E.SchuurJ. D.HeinemanJ.StoneR.WeissmanJ. S. (2009). Advance directives in nursing home residents aged ≥65 years: United States 2004. American Journal of Hospice and Palliative Medicine, 25(6), 476–482. https://doi.org/10.1177/1049909108322295
SchwebelF. J.LarimerM. E. (2018). Using text message reminders in health care services: A narrative literature review. Internet Interventions, 13, 82–104. https://doi.org/10.1016/j.invent.2018.06.002
47.
SilveiraM. J.KimS. Y. H.LangaK. M. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, 362(13), 1211–1218. https://doi.org/10.1056/NEJMsa0907901
TemelJ. S.GreerJ. A.MuzikanskyA.GallagherE. R.AdmaneS.JacksonV. A.DahlinC. M.BlindermanC. D.JacobsenJ.PirlW. F.BillingsJ. A.LynchT. J. (2010). Early palliative care for patients with metastatic non–small-cell lung cancer. New England Journal of Medicine, 363(8), 733–742. https://doi.org/10.1056/NEJMoa1000678
51.
TsengD. S.CoxE.PlaneM. B.HlaK. M. (2001). Efficacy of patient letter reminders on cervical cancer screening. Journal of General Internal Medicine, 16(8), 563–568. https://doi.org/10.1046/j.1525-1497.2001.016008567.x
52.
TulskyJ. A. (2005). Beyond advance directives: Importance of communication skills at the end of life. JAMA, 294(3), 359–365. https://doi.org/10.1001/jama.294.3.359
WangY.ZhangY.HongY.ZengP.HuZ.XuX.WangH. (2021). Advance directives and end-of-life care: Knowledge and preferences of patients with brain tumours from Anhui, China. BMC Cancer, 21(1), Article 25. https://doi.org/10.1186/s12885-020-07775-4
57.
WilsonD. M.HouttekierD.KunjuS. A.BirchS.CohenJ.MacLeodR.HewittJ. A. (2013). A population-based study on advance directive completion and completion intention among citizens of the western Canadian province of Alberta. Journal of Palliative Care, 29(1), 5–12. https://doi.org/10.1177/082585971302900102
58.
WrightA. A.ZhangB.RayA.MackJ. W.TriceE.BalboniT.MitchellS. L.JacksonV. A.BlockS. D.MaciejewskiP. K.PrigersonH. G. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 300(14), 1665–1673. https://doi.org/10.1001/jama.300.14.1665
59.
YadavK. N.GablerN. B.CooneyE.KentS.KimJ.HerbstN.ManteA.HalpernS. D.CourtrightK. R. (2017). Approximately one in three U.S. adults completes any type of advance directive for end-of-life care. Health Affairs, 36(7), 1244–1251. https://doi.org/10.1377/hlthaff.2017.0175
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