Improving Completion of Advance Directives in the Primary Care Setting: A Randomized Controlled Trial Heather Heiman, MD, David W. Bates, MD, MSc, David Fairchild, MD, Shimon Shaykevich, MS, Lisa Soleymani Lehmann, MD, PhD, MSc BACKGROUND: Since 1991, hospitals have asked patients whether they have advance directives, but few patients complete these documents. We assessed two simple interventions to im- prove completion of advance directives among elderly or chronically ill outpatients. METHODS: We conducted a cluster randomized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center. Patients were either 70 years of age or 50 years old with a chronic illness. The study comprised three arms: physician reminders recommending documentation of advance directives, physician reminders plus mailing advance directives to patients together with educational literature, or neither intervention (control). The main outcome measure was completion of an advance di- rective. RESULTS: After 28 weeks, 1.5% (5/332) of patients in the phy- sician reminder group, 14% (38/277) in the physician reminder plus patient mailing group, and 1.8% (5/286) in the control group had completed advance directives. In multivariate anal- yses, patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives (odds ratio [OR] = 5.9; 95% confidence in- terval [CI]: 1.5 to 22), whereas patients in the physician remind- er– only group were no more likely than controls to have com- pleted advance directives (OR = 0.88; 95% CI: 0.21 to 3.7). CONCLUSION: Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents. A physician reminder alone did not have an effect. Am J Med. 2004;117:318 –324. ©2004 by Elsevier Inc. M ore than a decade has passed since the Patient Self-Determination Act mandated that hospi- tals ask patients whether they have advance di- rectives and make these documents available (1). Ad- vance directives, which include health care proxies and living wills, are intended to promote patient autonomy and dignity at the end of life and to permit shared deci- sion making between patients and doctors (2). Yet, de- spite support from providers and the public, only a mi- nority of patients complete advance directives, and physicians are often unaware of the documents even when patients have executed them (3,4). Patient-physician discussions about patients’ wishes regarding future medical interventions may increase pa- tients’ satisfaction with their physicians (5–7), and the primary care clinic may be the best setting for discussions of advance directives. The Joint Commission on Accred- itation of Healthcare Organizations revised its hospital standards in 2002 to require that hospital-based ambula- tory clinics be equipped to assist patients with advance directives (8). Several studies have tested interventions to increase the completion of advance directives among outpatients (9 –14). It is difficult to generalize the results of these studies to a busy primary care setting, however, because they either took place in geriatric clinics or re- quired time-intensive interventions such as physician training sessions or patient visits with nurses or social workers. Simpler interventions such as computer-generated physician reminders have been shown to be effective in promoting preventive services such as blood pressure measurements and vaccinations (15), suggesting that such reminders can also help to increase the completion of advance directives. Dexter and colleagues found that computerized reminders to physicians were associated with up to a sixfold greater completion rate of advance directives as compared with no physician reminders (16). Patient mailings, another simple intervention, were shown to boost completion rates in two controlled trials that assessed the efficacy of mailings to older patients (17,18). One study (18) demonstrated that mailing the California Durable Power of Attorney for Healthcare led 18% of patients to complete an advance directive as com- pared with 0.4% of controls, whereas the other study From the Division of General Internal Medicine (HH), Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Division of General Medicine and Primary Care (DWB, DF, SS, LSL), Brigham and Women’s Hospital, Boston, Massachusetts; and Department of Social Medicine (LSL), Division of Medical Ethics, Harvard Medical School, Boston, Massachusetts. This study was funded in part by a grant (HS11046) from the Agency for Healthcare Research and Quality, and by the Gretchen and Ed Fish Education Fund. Requests for reprints should be addressed to Lisa Soleymani Leh- mann, MD, PhD, MSc, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, Massachusetts 02120, or llehmann1@partners.org. Manuscript submitted September 4, 2003, and accepted in revised form March 15, 2004. 318 © 2004 by Elsevier Inc. 0002-9343/04/$–see front matter All rights reserved. doi:10.1016/j.amjmed.2004.03.027