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Comparison of Web-Based and Paper Advance Directives: A Pilot Randomized Clinical Trial.

Joshua A Rolnick1,2,3,4, Francisca Oredeko2, Elizabeth Cooney-Zingman2

  • 1Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.

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Summary

A new web-based advance directive (AD) shows potential for improving documentation and sharing of care preferences in serious illnesses. While not statistically significant, the digital tool demonstrated a trend toward increased documentation compared to paper ADs.

Keywords:
advance directivesdigital healthelectronic health recordliving willweb-based advance care planningwebsites

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Area of Science:

  • Medical Informatics
  • Palliative Care
  • Health Technology

Background:

  • Digital tools for documenting care preferences in serious illnesses are emerging but their effectiveness is not well-established.
  • A novel web-based advance directive (AD) was developed with modular content, electronic health record (EHR) transmission capabilities, and nudges for document sharing.
  • The study aimed to evaluate the impact of this digital tool on advance care planning documentation and patient engagement.

Purpose of the Study:

  • To compare the efficacy of a web-based, EHR-transmissible advance directive (AD) against a traditional paper AD.
  • To assess the impact of digital tools on the documentation and sharing of patient care preferences.
  • To evaluate patient satisfaction and acceptability of different AD formats.

Main Methods:

  • A randomized controlled trial was conducted with patients diagnosed with gastrointestinal and lung malignancies.
  • Participants were assigned to either a web-based AD or a paper AD group.
  • The primary outcome was the proportion of patients with newly documented advance care plans in the EHR at 8 weeks, with secondary outcomes including satisfaction, acceptability, and surrogate sharing.

Main Results:

  • While not statistically significant (P = .14), the web AD group showed a higher proportion of new EHR documentation (28%) compared to the paper AD group (16%).
  • The odds of new documentation with the web AD were higher (OR 3.7), though not statistically significant (P = .10).
  • Patient satisfaction and AD acceptability were high and comparable across both groups; web AD users reported slightly higher sharing with surrogates (79% vs. 65%).

Conclusions:

  • Web-based advance directives show promise in enhancing the documentation and dissemination of patient care preferences.
  • Further research with larger sample sizes is necessary to confirm the impact on intermediate outcomes and patient-centered results.
  • Digital platforms may facilitate better communication and adherence to care wishes in serious illness.