The recent Institute of Medicine report “Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life” endorses advance care planning (ACP) as a key component of quality healthcare. In contrast to the prevailing model of engaging only individuals with serious illness in ACP, it proposes a continuous process, starting earlier in the lifespan with individuals in good health. Such an approach helps to prepare the individual for more in-depth discussions and treatment decision making as more serious illness develops. This project is responsive to this call. It builds upon earlier work of the Principal Investigator (PI) providing two key insights for improving the process of ACP. The first of these is shifting the purpose of ACP away from the pre-specification of treatment preferences to preparation for making the best possible “in-the-moment” healthcare decisions. This is accomplished by conceptualizing ACP as acts of communication among patients, surrogates, and clinicians. The second is explicitly addressing the many attitudinal, cognitive, and behavioral barriers to engagement in ACP. This is accomplished by treating ACP as a health behavior and intervening using validated models for health behavior change. The PI has developed and pilot-tested an intervention based on the Trans-Theoretical Model. This intervention consists of an expert system that assesses an individual's readiness to engage in ACP along with the attitudes and beliefs influencing the desire, motivation, and ability to engage. It then provides individually tailored feedback materials providing information, motivation, and/or behavior change strategies (computer-tailored information or CTI). This project will also utilize a form of motivational interviewing called motivational enhancement therapy (MET), which, while also including the concept of readiness for behavior change, is distinct from CTI. It consists of brief counseling exploring an individual's readiness to engage in behavior change and helping the individual to identify motivators for change. The objective of the project is to examine the effects of CTI and MET on Veteran engagement in ACP. The specific aim is: To conduct a randomized controlled trial examining the effects of: a) usual care; b) CTI; c) MET; d) CTI + MET on the proportion of middle-age and older Veterans receiving primary care at the VA who complete the process of ACP. Broad eligibility criteria will be used to identify Veterans age 55 years and older who are receiving primary care within VA Connecticut Healthcare System and who have not completed all of the 4 key ACP behaviors: health care proxy assignment, living will completion, communication with the health care proxy about views on quality vs. quantity of life, communication with the clinician about these views. The intervention(s) will be delivered over the phone. For Veterans receiving CTI, an individually tailored feedback report, a stage-matched brochure, and a pamphlet for the surrogate will be mailed. This will be repeated at 2 and 4 months. For Veterans receiving MI, the Veteran and surrogate will participate in a dyadic interview. Follow-up interviews will occur at 2 and 4 months. For Veterans receiving CTI + MI, the printed materials will be mailed, and the interview will be conducted within 2 weeks. Baseline measures, including stage of change for the 4 key ACP behaviors, pros and cons of behavior change, and health status and sociodemographic variables, will be obtained for all participants. The outcome measure, obtained at 6 months, will be the proportion of participants who have completed the 4 ACP behaviors. The proposal will also lay the groundwork for more widespread implementation by collecting implementation data on the time and effort required to deliver the interventions, success of and barriers to delivering the interventions, and spill-over effects on other clinical services. Additional work will be done to strategize about the most efficient ways to embed the interventions into existing clinical services.

This randomized controlled trial takes a public health approach to the engagement of Veterans in advance care planning (ACP). This is the process by which Veterans and their surrogates can prepare for future treatment decisions. ACP helps to ensure that Veterans' preferences for care are honored at the end-of-life and decreases the burden on loved ones who may need to make surrogate medical decisions. The study seeks to examine the effect of two interventions, designed to be delivered to a broad cross-section of Veterans and their surrogates, on increasing engagement in ACP.