Understanding Advance Care Planning as a Process of Health Behavior Change
Terri R. Fried MD
From the * Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut † Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut ‡ School of Social Work, University of Connecticut, Farmington, Connecticut § Braceland Center for Mental Health and Aging, Institute of Living/Hartford Hospital, Hartford, Connecticut; and ∥ Program on Aging, School of Medicine, Yale University, New Haven, Connecticut.
Search for more papers by this authorKaren Bullock PhD
From the * Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut † Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut ‡ School of Social Work, University of Connecticut, Farmington, Connecticut § Braceland Center for Mental Health and Aging, Institute of Living/Hartford Hospital, Hartford, Connecticut; and ∥ Program on Aging, School of Medicine, Yale University, New Haven, Connecticut.
Search for more papers by this authorLynne Iannone MA
From the * Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut † Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut ‡ School of Social Work, University of Connecticut, Farmington, Connecticut § Braceland Center for Mental Health and Aging, Institute of Living/Hartford Hospital, Hartford, Connecticut; and ∥ Program on Aging, School of Medicine, Yale University, New Haven, Connecticut.
Search for more papers by this authorJohn R. O'Leary MA
From the * Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut † Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut ‡ School of Social Work, University of Connecticut, Farmington, Connecticut § Braceland Center for Mental Health and Aging, Institute of Living/Hartford Hospital, Hartford, Connecticut; and ∥ Program on Aging, School of Medicine, Yale University, New Haven, Connecticut.
Search for more papers by this authorTerri R. Fried MD
From the * Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut † Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut ‡ School of Social Work, University of Connecticut, Farmington, Connecticut § Braceland Center for Mental Health and Aging, Institute of Living/Hartford Hospital, Hartford, Connecticut; and ∥ Program on Aging, School of Medicine, Yale University, New Haven, Connecticut.
Search for more papers by this authorKaren Bullock PhD
From the * Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut † Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut ‡ School of Social Work, University of Connecticut, Farmington, Connecticut § Braceland Center for Mental Health and Aging, Institute of Living/Hartford Hospital, Hartford, Connecticut; and ∥ Program on Aging, School of Medicine, Yale University, New Haven, Connecticut.
Search for more papers by this authorLynne Iannone MA
From the * Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut † Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut ‡ School of Social Work, University of Connecticut, Farmington, Connecticut § Braceland Center for Mental Health and Aging, Institute of Living/Hartford Hospital, Hartford, Connecticut; and ∥ Program on Aging, School of Medicine, Yale University, New Haven, Connecticut.
Search for more papers by this authorJohn R. O'Leary MA
From the * Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut † Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut ‡ School of Social Work, University of Connecticut, Farmington, Connecticut § Braceland Center for Mental Health and Aging, Institute of Living/Hartford Hospital, Hartford, Connecticut; and ∥ Program on Aging, School of Medicine, Yale University, New Haven, Connecticut.
Search for more papers by this authorAbstract
OBJECTIVES: To explore whether models of health behavior change can help to inform interventions for advance care planning (ACP).
DESIGN: Qualitative cross-sectional study.
SETTING: Community.
PARTICIPANTS: Sixty-three community-dwelling persons aged 65 and older and 30 caregivers with experience as surrogate decision-makers.
MEASUREMENTS: In focus groups conducted separately with older persons and caregivers, participants were asked to discuss ways they had planned for future declines in health and why they had or had not engaged in such planning. Transcripts were analyzed using grounded theory.
RESULTS: Four themes illustrated the potential of applying models of health behavior change to improve ACP. (1) Participants demonstrated variable readiness to engage in ACP and could be in different stages of readiness for different components of ACP, including consideration of treatment goals, completion of advance directives, and communication with families and physicians. (2) Participants identified a wide range of benefits of and barriers to ACP. (3) Participants used a variety of processes of change to progress through stages of readiness, and ACP was only one of a broader set of behaviors that participants engaged in to prepare for declines in their health or for death. (4) Experience with healthcare decision-making for loved ones was a strong influence on perceptions of susceptibility and engagement in ACP.
DISCUSSION: The variability in participants' readiness, barriers and benefits, perceptions of susceptibility, and use of processes to increase readiness for participating in each component of ACP suggests the utility of customized, stage-specific interventions based on individualized assessments to improve ACP.
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