Background
An Advance Directive (AD) is a legally binding instruction about a person’s future medical care in advance, in the event he or she later becomes unable to participate in decision making process about his or her care [
1]. It promotes patients’ autonomy and patient empowerment based on each individual’s personal values and perceptions, cultural background, and goals and expectations of care [
2,
3]. Since its conception, ADs have been widely promoted and supported worldwide as a critical part of Advance Care Planning (ACP). In the United States, Congress passed Patient Self Determination Act in 1991 that required healthcare facilities to inquire about ADs on a statutory basis [
4].
However, the completion rate of ADs has been low [
5‐
8], despite its well documented positive impact on patient care, including better satisfaction with physicians and clinic visits [
9], decreased healthcare cost and utilization [
10], decreased chances of demise in the hospital and use of life-sustaining treatment [
11]. Population-based study estimated the rate of completed ADs ranged from 5—15% in the US [
12]. This obvious contrast has led to many studies exploring potential barriers to completion of ADs, including low awareness and lack of knowledge of ADs from patients [
13,
14] and lack of dedicated time by physicians [
15]. These findings have led to efforts in developing effective solutions to promote completion of ADs. Several interventional studies have demonstrated success and shown that patient education and communication can be effective in promoting AD completion [
16‐
19]. A recent systematic review on various interventions used to promote end-of-life planning suggested that the most effective method to increase the uptake of such plans is the combination of informative material and repeated conversations over clinical visits [
20].
Primary care settings provide great opportunities for interventional efforts to address the issue of low AD completion rates where majority of patients receive their usual care. Primary care physicians’ training uniquely emphasizes holistic care, coordination of care, and excellent communication and thus they are best prepared to discuss ADs [
3,
9]. It was also reported that primary care patients have high willingness to have ADs and both the young and the healthy subgroups expressed at least as much interest in planning ADs as those older than 65 and those in fair-to-poor health [
21]. Patients also want their primary care doctors to initiate ACP earlier in the patient-physician relationship, earlier in their disease process, and while they are still in good health [
22,
23]. Thus, it is imperative to develop effective strategies to increase the completion of ADs in primary care setting. A systematic review in 2007 on interventions to increase AD completion in the primary care setting showed that successful interventional programs often involved direct patient–health care professional interactions in iterative interactions over multiple visits whereas passive patient education materials may be ineffective [
24].
An important gap in the current medical literature is that the existing intervention studies on completion of ADs in primary care settings were mostly in western countries. To the best of our knowledge, no randomised controlled trial has been conducted in Asia. We hypothesized that active counseling would similarly increase the completion rate of ADs in Singapore because AD is a comprehensive dialogue and process about a person’s health preferences in end-of-life scenarios, and direct interactions between individuals and health care professionals provide them with the opportunity to clarify their queries and offer assistance during the process of discussing and filling in an AD; however, it is well known that discussions on end-of-life issues are heavily influenced by cultural and societal factors, and there is no prior evidence on whether the above-mentioned strategies to improve completion of ADs may work in an Asian society with different ethnic and cultural backgrounds, and social values and philosophies. Singapore is a multi-ethnic, multicultural urban city state in Southeast Asia that faced the similar issue of low AD completion rate. Although Advance Medical Directive (AMD) Act was passed in Singapore Parliament in May 1996, its uptake by the public remains low [
25].
In this randomized controlled trial conducted in Singapore, we aim to examine the effectiveness of two interventional strategies, namely 1) active counseling sessions coupled with passive patient education pamphlets, and 2) patient education pamphlets alone, compared with 3) control group (usual care), in increasing the completion rates of ADs in the primary care setting.
Conclusion
This randomized controlled trial did not support the use of patient education pamphlets with or without active counseling session in increasing the completion of ADs in primary care setting in Singapore. The optimal intervention strategy depends on each health system’s context and resources, taking into consideration patients’ profiles, which deserves further studies.
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