Influencing advance directive completion rates in non-terminally ill patients: A systematic review

Purpose: To conduct a systematic review of educational advance care planning interventions directed at patients without terminal illness to determine their influence on the completion rate of advance directives (AD). Materials and Methods: We searched MEDLINE; Co-chrane Library, and reference lists of all pertinent retrieved articles for randomized trials (RCTs), restricted to English language and adults greater than or equal to18 years. Two investigators independently and in duplicate determined trial eligibility. We included published RCTs evaluating an educational intervention comprised of at least one of; written, audio, or video materials, or direct counseling, and if an outcome included AD completion rate. Results: Nine RCTs (N=3,206) were included. Overall, methodologic quality and reporting transparency were poor. The median composite quality score was 5 (range, 0-10). The odds ratios for AD completion rates ranged from 0.41 to 106.0 across the trials (test of heterogeneity P < .001). The summary odds ratio for these educational interventions was 3.71 (95% C.I. 1.46, 9.40). Trials with greater methodologic rigor and reporting transparency produced a more conservative estimate of effect, 2.42 [0.96, 6.10] versus 28.69 [5.08, 162.06] for less rigorous and poorly reported trials (P = .013). Conclusions: Advance directive completion rates documenting patient preferences for end-of-life care may be increased by simple patient-directed educational interventions. (C) 2004 Elsevier Inc. All rights reserved.