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Default options in advance directives: study protocol for a randomised clinical trial.

Nicole B Gabler1, Elizabeth Cooney1, Dylan S Small2

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Summary

Redesigning advance directives (ADs) to default to comfort care, instead of aggressive treatment, may improve patient-centered outcomes for seriously ill individuals. This approach ensures care aligns with patient wishes, reducing burdensome interventions.

Keywords:
Advance directiveDefault optionRandomized clinical trial

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Area of Science:

  • Medical Ethics
  • Palliative Care
  • Health Services Research

Background:

  • Seriously ill patients often receive aggressive end-of-life care against their wishes, as current advance directives (ADs) require active choices to limit interventions.
  • Traditional ADs may not adequately capture patient preferences, leading to care that is not patient-centered.
  • A shift towards default comfort-oriented care in ADs could better align medical interventions with patient values.

Purpose of the Study:

  • To test the hypothesis that a redesigned advance directive (AD) defaulting to comfort-oriented care improves patient-centered outcomes.
  • To compare patient-centered outcomes across three different AD models: traditional, default life-extending, and default comfort care.
  • To evaluate the impact of AD design on hospital-free days and other secondary outcomes in seriously ill adults.

Main Methods:

  • A multicenter trial randomizing seriously ill adults to one of three AD types.
  • Participants receive either a traditional AD, an AD defaulting to life-extending care, or an AD defaulting to comfort care.
  • The primary outcome is hospital-free days; secondary outcomes include healthcare utilization, costs, and patient/surrogate satisfaction.

Main Results:

  • This section is not applicable as the study is pre-results.
  • The study is designed to detect differences in the primary outcome of hospital-free days.
  • Secondary outcomes will provide comprehensive data on the effectiveness and patient experience of different AD models.

Conclusions:

  • This study will provide crucial evidence on whether defaulting to comfort care in advance directives enhances patient-centered outcomes.
  • Findings are expected to inform best practices in end-of-life care planning and advance directive design.
  • The research aims to promote more compassionate and aligned care for seriously ill patients at the end of life.