doi: 10.1111/j.1369-7625.2008.00517.x
Development of an interactive computer program for advance care planning Michael J. Green MD MS* and Benjamin H. Levi MD PhD *Professor, Departments of Humanities and Medicine, Associate Professor, Departments of Humanities and Pediatrics, Penn State College of Medicine, Hershey, PA, USA
Abstract Correspondence Michael J. Green Departments of Humanities and Medicine Penn State College of Medicine C1743, 500 University Drive Hershey PA 17033 USA E-mail:
[email protected] Accepted for publication 20 June 2008 Keywords: advance directives, computer assisted instruction, decision aids, decision making, surrogate decision making
Objective To describe the development of an innovative, multimedia decision aid for advance care planning. Background Advance care planning is an important way for people to articulate their wishes for medical care when they are not able to speak for themselves. Living wills and other types of advance directives are the most commonly used tools for advance care planning, but have been criticized for being vague, difficult to interpret, and inconsistent with individualsÕ core beliefs and values. Results We developed a multimedia, computer-based decision aid for advance care planning (ÔMaking Your Wishes Known: Planning Your Medical FutureÕ) to overcome many of the limitations of standard advance directive forms. This computer program guides individuals through the process of advance care planning, and unlike standard advance directives, provides tailored education, values clarification exercises, and a decision-making tool that translates an individualÕs values and preferences into a specific medical plan that can be implemented by a health-care team. Pilot testing with 50 adult volunteers recruited from an outpatient primary care clinic showed high levels of satisfaction with the program. Further pilot testing with 34 cancer patients indicated that the program was perceived to be highly accurate at representing patientsÕ wishes. Conclusions This paper describes the development of an innovative decision aid for advance care planning that was designed to overcome common problems with standard advance directives. Preliminary testing suggests that it is acceptable to users and is accurate.
Introduction Background on advance care planning Advance care planning is a process that facilitates individualsÕ involvement in medical decision making when they cannot speak for themselves. It
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is typically implemented through advance directives outlining specific health-care instructions and ⁄ or designating a proxy decision-maker for those decisions. In the USA, federal policy embraces advance directives through the Patient Self-Determination Act.1 Legislation supporting advance directives has been passed in all 50 states;
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and the public has been strongly encouraged to complete such forms, particularly following the turmoil regarding the end-of-life wishes of Terri Schiavo.2 Despite widespread agreement that individuals ought to plan for their medical futures, advance directive completion rates have remained consistently low.3 Many patients who complete advance directives fail to understand key elements of these documents4,5 and even when completed, there are often barriers to their being implemented.6,7 If individuals are to receive medical care that is consistent with their values, goals, and wishes, there is a need to improve the way people engage in advance care planning.7 In this paper, we describe the development of an innovative, multimedia, interactive, computer-based decision aid, ÔMaking Your Wishes Known: Planning Your Medical FutureÕ, designed to overcome many of the limitations of standard living wills and advance directive forms. The computer program guides individuals through the process of advance care planning. Unlike standard advance directives, the computer program includes tailored education, values clarification exercises, and a decision-making tool that translates an individualÕs goals and preferences into a specific medical plan that can be implemented by a health-care team. The need for advance care planning Studies have shown that at the time end-of-life decisions must be made, up to 75% of adults lack decision-making capacity,8 yet fewer than 25% have completed advance directives.9 Even among critically ill patients with cancer, one study found only a 27% completion rate.10 This lack of planning can lead to numerous problems, such as decisions being made in the heat of the moment rather than with foresight and planning,5 moral distress and conflict for health-care providers,11 unintended financial burdens to patients, families and society,12 and perhaps most importantly, medical care that is inconsistent with an individualÕs values and wishes.13 While doctors typically turn to family members for decision making when patients cannot speak for themselves, studies have demonstrated that
neither families nor doctors accurately predict what patients want,14,15 a situation that cannot be remedied without explicit discussion and planning in advance. Barriers to effective advance care planning For years, physicians, lawyers and others have extolled the value of advance care planning.16 But increasingly, concerns have been raised that advance directives and living wills are not effective tools for articulating or implementing a patientÕs plans.7,13 Researchers have identified numerous limitations to standard methods of advance care planning, such as: (1) individuals are often uncomfortable talking about end-oflife issues and thus procrastinate or avoid such conversations;17 (2) physicians do not initiate advance care planning discussions for fear that it will induce anxiety or rob patients of hope,18 or that discussions may be inappropriate;19 (3) individuals typically lack the medical knowledge to complete advance directive forms without guidance;20 (4) individuals change their minds about which medical interventions they want and do not want;21 (5) commonly used advance directive forms are either too vague or fail to provide specific, detailed practical guidance, thus lending themselves to misinterpretation by family members or health-care providers;22 (6) advance directive documents often fail to accurately reflect a personÕs actual values, goals and preferences for health care11 and (7) cultural and ethnic attitudes about end-of-life issues differ, affecting some minority groupsÕ willingness to participate in advance care planning.23 For such reasons, even when an advance directive is present in a patientÕs medical record, health-care professionals often doubt their relevance and authenticity and thus, disregard them or rely on family members to make medical decisions.24 Strategies for improving advance care planning Over the years, there have been numerous efforts to improve advance care planning. Some efforts have focused on strategies for increasing
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advance-directive completion rates25 using techniques such as computer-generated reminders, dissemination of educational materials, and targeted mailings. Others have focused on the creation of more meaningful advance directive documents such as Ôvalues historiesÕ,26 detailed preference directives27 and disease-specific directives.28 While some of these efforts have had modest success, only the most intense community-wide efforts have made substantive overall improvements in advance care planning,29 and these intensive efforts are difficult to replicate. Still needed is an efficient and easily implemented method for advance care planning that individually tailors information, helps people clarify and articulate their values and goals, and generates a finished document that is consistent, clear, medically sound and readily accessible.
Methods Development of a computer program for advance care planning With these shortfalls in mind, we created an interactive computer program for advance care planning, called ÔMaking Your Wishes Known: Planning Your Medical FutureÕ. This program has been a collaborative effort involving experts in medicine, nursing, bioethics, geriatrics, decision-analysis, law, graphic art, instructional design and education. Production followed a systematic approach,30 starting with a comprehensive review of the literature on advance care planning and risk communication. We then used a modified Delphi technique to reach consensus on program content, developing and modifying scripts using several core resources. These included materials on advance care planning that we developed for a community outreach project, courses for medical students, workshops for health-care professionals, and the workbook ÔYour Life Your Choices – Planning for Future Medical DecisionsÕ.31 Scripts were transformed into screen shots, and we created audio and video content to integrate into the program. Using an iterative process, we refined all aspects
of the program after alpha testing with students, patients, nurses, physicians and community volunteers. The current beta version of the program has an estimated eighth grade-reading level (Flesch–Kincaid), and a Flesch Reading Ease Score of 60.2 (approximately the level of ReaderÕs Digest). Selected screen shots are shown in Fig. 1. The program has several notable benefits over other standard advance directive materials. First, it is a multimedia production with audio, video, and interactivity – which users report they find very engaging (video samples can be found at http://www.hmc.psu.edu/humanities/Advance% 20Directives%20Project.htm). Second, by taking an educational and reflective approach to decision making, it emphasizes the process of advance care planning, helping users to think through the salient issues and communicate their wishes to friends, family, and health-care providers. Third, the program also provides detailed information needed by both individuals and their physicians for future decisions. The program accomplishes these goals by: (i) integrating values clarification exercises to help individuals reflect on their goals, values and priorities for end-of-life care; (ii) posing hypothetical clinical scenarios, offering diverse testimonials, and providing options for supplementary information on clinical conditions and treatment options to help individuals more accurately forecast their wishes; and (iii) utilizing a sophisticated decision aid that both guides users through the process of making choices, and translates their goals and values into a specific medical plan that can be implemented by physicians.
Results Program content Our computer program is comprised of six sections, plus an optional tutorial on how to use the program: 1. Getting Started describes the goals, importance and key components of advance care planning, provides an overview of the program
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Figure 1 Sample screen shots of ÔMaking Your Wishes Known: Planning Your Medical FutureÕ.
and its various features, and explains how to navigate, complete exercises, save materials and print. 2. Choosing a Spokesperson reviews the concept of a surrogate decision-maker, including how to choose a spokesperson, designate someone as durable power of attorney and discuss decisions with this person. Through a question–answer format, users are then prompted to designate individuals to be their primary or alternate spokesperson(s). 3. Exploring Your Values asks users a series of questions about their personal values and goals regarding medical care, death and dying, and disability. This information becomes data for the decision aid that will help users make choices about medical treatment and generate a detailed advance directive for health care.
4. Your Medical Wishes helps users think about various medical interventions, and asks a series of questions whose answers contribute to the eventual detailed advance directive. This section uses video, photos, text and narratives to explain common health conditions (such as stroke, dementia, coma, and terminal illness) that can prevent a patient from communicating his or her preferences for medical treatments. There is a description of each condition and its consequences, what it is like to experience these medical conditions, and what treatment options are available. In similar fashion, this section describes medical interventions that commonly involve life and death decisions (i.e. CPR, mechanical ventilation, dialysis, tube feeding, and hospice ⁄ palliative care). Beyond the basic information provided for each condition and
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treatment, users may access additional information through an on-screen link. Subsequently, they are prompted to make a series of decisions about various conditions and treatments – which provides data used by the decision aid to individualize the eventual advance directive. 5. Putting It All Together is a summary section based on the information previously gathered. In this section, the program uses the decision aid to generate a printable document that articulates what the individual wants and who (if anyone) has been designated as a surrogate decisionmaker. Included in this is one of the six general philosophical statements that an individual may accept, edit, or choose another to best reflect his or her general stance toward potentially lifesustaining medical interventions. Additionally, the generated advance directive contains the userÕs specific wishes for particular medical conditions and treatments, including those states of being that would constitute (for that individual) an unacceptable quality of life. After confirming or revising these choices, the document may be saved, printed and distributed as a formal advance directive. 6. The Next Step reinforces the importance of communicating oneÕs wishes to loved ones, health-care professionals, and others who might be involved in medical decision making. Recommendations on how to initiate and sustain conversations on these issues are also provided. Throughout the program, the user can access video clips of patient stories (or ÔtestimonialsÕ) for five individuals who describe their own experiences dealing with the particular topic being addressed (samples available for viewing at http://www.hmc.psu.edu/humanities/ Advance%20Directives%20Project.htm). While the use of patient testimonials is controversial because of concerns about selection bias and unintended persuasion,32 we include them in our program primarily to portray varied perspectives, rather than to provide prescriptive influence about how decisions should be made. The differences in experience, age, gender, ethnicity and background are used to illustrate
that advance care planning is relevant to a broad audience. Users are encouraged to proceed through the program in the sequence provided, but are also free to navigate the program in any order they wish. That said, certain sections must be completed before the program can generate a final advance directive. A description of our decision aid The most innovative aspect of our program is the use of a decision aid to help individuals make choices about the medical treatment they would want if unable to speak for themselves. The decision aid is based on Multi-Attribute Utility Theory (MAUT), a type of decision analysis that systematically weighs competing objectives and can help translate a personÕs values and goals into a medical plan of action for complex decisions. Multi-Attribute Utility TheoryÕs key premises are (1) when choosing between alternatives, the best choice maximizes positive outcomes and minimizes negative ones33 and (2) a personÕs choices can be accurately ranked by a mathematical formula that calculates his ⁄ her preferences for different aspects (or attributes) of choices. MAU models have been successfully applied to various health-care scenarios where there is no clear correct decision, such as mammography screening in younger women, family planning, flu vaccination and follow-up for abnormal Pap smears. But, to our knowledge, they have not yet been used for advance care planning. What makes MAUT particularly well-suited for advance care planning is its ability to account for individual attributes of a decision, weigh the relative importance of each attribute, and synthesize a personÕs diverse values and desires into a single choice that optimizes their preferences. We have integrated a multi-attribute utility model into our computer program as a way to help individuals reflect on decisions, prioritize their values, and develop a rational plan that is consistent with their wishes.
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Development of the MAU model The MAU model we use in our program follows a six-step approach:34 (1) identify decisions that need to be made; (2) identify important attributes of the decisions to be made; (3) have individuals assign important weights to each attribute; (4) have individuals rate the decision components using the attribute matrix previously developed; (5) calculate an overall preferences score for each decision, and (6) return results back to participants for revisions and ⁄ or confirmation. To identify and refine the ÔattributesÕ (i.e. factors) influencing individualsÕ decisions whether to receive life-saving medical treatment, we first reviewed the published literature on qualitative assessments of individualsÕ preferences for endof-life care. After identifying a preliminary list of attributes, we next conducted four individual interviews and four focus groups to refine this list and to test it for face and content validity. We enrolled 23 individuals, including nine from a community geriatrics centre, seven from an urban community center with a predominantly minority population, and seven from cancer support groups at an academic medical center. Using accepted focus group methodology,35 we asked participants to identify factors that would influence their decisions whether or not to receive life-saving medical treatments, and then facilitated a semi-structured discussion to identify common themes and patterns. All interviews and focus groups were audiotaped and transcribed, and two investigators independently reviewed the transcripts, identified themes, compared results, and reached consensus about categories. Participants were eager to discuss end-of-life planning, often reporting the lack of opportunity to do so with health-care providers. Content analysis of focus group transcripts demonstrated a strong consensus that the following attributes were most important in deciding whether to receive medical treatment when unable to speak for oneself. As such, they were integrated into the MAU model of our program, where they are rank ordered by users, and then assigned numerical scores so as to weight their priority.
• The physical symptoms associated with the condition. • The effect of the condition on oneÕs mental functioning. • The effect of the condition on oneÕs independence. • The prognosis of the condition. • Whether the condition would make one a burden to others. • The burden of the medical treatment. • Whether the treatment would make one a burden to others. The list of attributes are integrated into the program to help the individual make decisions about the use of particular interventions under a variety of clinical circumstances. For example, users are asked to imagine suffering a moderate ⁄ severe stroke that would improve during the next year and to consider whether they would want an intervention such as mechanical ventilation for that condition. By assessing how the condition and intervention rate for various attributes (e.g. whether mechanical ventilation for a stroke is burdensome to oneself or others), the program (via the MAU model) is able to prioritize the individual wishes for a variety of condition-treatment combinations. The program also helps individuals articulate what counts as Ôpoor quality of lifeÕ by asking how acceptable various states of dysfunction would be to them. Users articulate whether particular situations would be ÔacceptableÕ, Ôacceptable but difficultÕ, Ôworth living but just barelyÕ, or Ônot worth livingÕ (with a fifth option being Ônot sureÕ). Five physical aspects are explored (pain, discomfort, incontinence, and moderate or severe immobility), three mental aspects (communication, confusion, decision making), and four social aspects (independent living, relationship, financial burden, and burden to family). Those Ôstates of beingÕ judged to be either Ônot worth livingÕ or Ôworth living but just barelyÕ are subsequently listed in the advance directive as indications of what Ôpoor quality of lifeÕ means for that individual. In the final part of the Putting It All Together section, individuals are given the opportunity to
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review and revise their choices for various conditions and treatments. Additionally, they are asked whether they wish to revise their choice of spokesperson(s); whether they want their spokesperson or their written advance directive to take precedence in the event of a conflict; whether they would want to participate in clinical research; whether they wish to be an organ donor and whether there are specific personal or spiritual wishes they would like to express. When users are satisfied that they have accurately expressed their wishes, they can print an advance directive document that can be signed, witnessed, and given to physicians and loved ones. Pilot evaluation Preliminary testing of the program has shown that individuals find it easy to use and they perceive it to be accurate at representing their values and preferences. In a pilot evaluation with 50 adult volunteers recruited from an internal medicine outpatient practice in central Pennsylvania (mean age 52 years, 68% female, 68% college graduates), users spent an average of 106 min completing the program, and they indicated that this duration of time was not burdensome. Users were very satisfied with the program overall (mean satisfaction = 8.5, where 1 = not at all satisfied and 10 = extremely satisfied), and particularly with how it improved their knowledge and helped them make decisions (mean 4.2, where 1 = very dissatisfied and 5 = very satisfied). In another pilot study, 34 individuals with cancer were recruited from clinics at Penn State Hershey Medical Center (mean age 57 years, 71% female, 53% with breast or lung cancer). Satisfaction was also very high in this group (mean = 8.5, where 1 = not at all satisfied and 10 = extremely satisfied). Furthermore, users indicated that the program was highly accurate at representing their wishes; prior to making edits to the computer-generated advance directive, mean accuracy was 5.5 (1 = not at all accurate, 7 = very accurate), and this increased to 6.5 post-editing (P < 0.001). And, as we
expected, users had no change in levels of hopefulness, hopelessness, or anxiety following the intervention. Some anticipated critiques and our response While we believe our interactive computer program offers numerous advantages over standard advance directive forms, no program is perfect, and we anticipate several potential critiques. (1) A computer program is too complex for those who are old, sick, or poorly educated. Though computers cannot overcome all the barriers to advance care planning (nor should they be seen as a replacement for medical professionals), they do have the potential to help individuals be better prepared for end-of-life health-care decisions. Computers have been shown to be widely accepted by people regardless of socioeconomic status, educational background, or age.36 Even in older adults with no prior computer experience and individuals with low literacy skills, computer-based education has outperformed traditional text-based education,37 and has been shown to increase self-esteem, as well as self-perceived productivity38 and autonomy.39 The use of computers in health care is widely accepted, and numerous studies have confirmed their effectiveness and acceptability for patient education,40 social support,41 taking medical histories,42 improving surgical management,43 promoting patient preferences44 and adherence to medication,45 and even providing psychological counselling.46 Our own work has demonstrated that computers can increase knowledge about breast cancer genetic testing and help people make difficult, value-laden choices.47,48 Add to this the ability of computers to compensate for sensory deficits such as impaired vision or hearing, and the potential impact of a well-designed computer program for advance care planning is enormous. (2) People are not able to make meaningful and ⁄ or reliable decisions about medical conditions with which they have had little or no experience. Future forecasting is notoriously inaccurate, and people often overestimate the negative aspects of
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illness and underestimate their ability to cope with physical challenges.49 The problem with inaccurate future forecasting is a serious one, but not specific to computerbased advance care planning. While people may not be able to predict with absolute confidence what they would want in the future, our program is designed to inform and educate, using vignettes, personal testimonials, didactic tutorials, and values-clarifying questions. Even if an individual fails to accurately predict what they will eventually want, we believe our program gives them a viable opportunity to learn about and reflect on potential future scenarios. Furthermore, the alternative to planning and predicting is to NOT plan or predict, which leaves decisions in the hands of people who are even less qualified to know what a person would want. Thus, in our assessment, it is better to try and sometimes be wrong than to not try at all. (3) Given people’s difficulties with predicting what they would want for themselves, we should not rely on surrogate decision-makers to make good, representative decisions on behalf of others.7 The literature on surrogate decision making reveals that surrogates tend to be poor predictors of patientsÕ wishes, incorrectly predicting their preferences one-third of the time.15 In an effort to overcome this problem, our program emphasizes the importance of discussing oneÕs wishes with both spokesperson(s) and health-care providers. In addition to specific advice about how to initiate and carry out such conversations, the program also lends itself to being used jointly, and models the conversational approach that we believe can improve the quality and accuracy of surrogate decision making. The bottom line is that medical decisions at the end of life are not optional; they must be made one way or another. Hence, the question is what is the best way to help those who must make these often-difficult decisions and can our computer-based decision aid can do a better job than standard advance directives? We contend that individuals who learn about the nature and implications of common end-of-life conditions and interventions will be better prepared to
make decisions that are consistent with their wishes. For this reason, education is a major focus for our program: providing information, opportunity for reflection, and encouraging people to think through the implications of their choices. That people might change their minds or poorly predict their future wishes speaks to a limitation of all anticipatory decision making. In the case of surrogates, who often must make end-of-life decisions for patients, we contend that they will be better prepared to accurately represent patientsÕ wishes to the extent that such decisions are anticipated, reflected on and discussed.
Conclusion We have developed an interactive computer program for advance care planning. Our program is innovative, educational, nuanced, and user-friendly. In future publications, we will address some general criticisms of advance directives. But outcomes speak louder than words, and it will be important to show that our computer program is actually effective. In ongoing research, we are evaluating how our program performs in real-life settings, comparing it via a randomized, controlled trial to a standard advance directive document. Ultimately, we hope to show that our program for advance care planning can significantly improve both doctorsÕ knowledge of patientsÕ wishes and their adherence to these wishes through the appropriate application (and ⁄ or restriction) of life-sustaining medical treatment. If it succeeds, it will achieve the important dual goals of providing needed education and promoting respect for patient autonomy.
Acknowledgement The project described was supported by grant number 1 R21 NR008539 from National Institute of Nursing Research, National Institutes of Health. Its content are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of
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Health. We also received support from the American Cancer Society (grant Number RSGHP-08-005-01-CPHPS), and various funding from Penn State University (the Social Science Research Institute, the Woodward Endowment for Medical Science Education, and the Tobacco Settlement Fund Award). The authors wish to acknowledge the support and assistance of Dr. William Lawrence for his contribution to the MAUT model used in this program, Dr. Cheryl Dellasega for her leadership in focus group activities, Charles Sabatino for his review of legal aspects of the program, Dr. Robert Pearlman and his collaborative team for use of the advance care planning booklet ÔYour Life, Your Choices,Õ Joanne Caulfield for assistance in grant preparation and project organization, and the Instructional Media Development Center at the University of Wisconsin for production and programming of the decision aid.
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