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Influencing advance directive completion rates in nonterminally ill patients: a systematic review


Advance directives (AD) in the form of cardiopulmonary resuscitation orders are a specific set of interventions in response to a cardiopulmonary arrest. A priori documentation and subsequent availability of ADs at the point of care increases the probability that diagnostic, therapeutic and palliative interventions will be administered to patients within the framework of these preferences.


We conducted a systematic review of educational advance care planning interventions for adults without terminal illness to determine their influence on the completion rate of advance directives for cardiopulmonary resuscitation.


We searched MEDLINE, the Cochrane Library, all retrieved trials and pertinent reviews for trials published between 1981 and September 2002. We included randomized trials enrolling patients ≥ 18 years of age, evaluating an educational intervention comprised of at least one of: written, audio, or video materials, or direct counseling, and whether an outcome included the completion rate of an advance directive. We appraised the quality of each trial in terms of methodology and reporting transparency (quality score range 0–10).


We included nine randomized trials enrolling 3206 patients. A variety of interventions were evaluated, primarily among Caucasian patients, including direct individual counseling, brochures, both direct counseling and brochures, and direct counseling plus brochures with a video presentation. Some trials included reminders as part of the intervention. Overall, the methodologic quality and reporting transparency were poor, reflected in a median composite quality score of 5 (interquartile range 4.5–6.0). The odds ratios for the completion rate of an advance directive ranged from 0.41 to 106.0 across the trials (test of heterogeneity P < 0.001). The summary odds ratio for these educational interventions was 3.71 (95% CI 1.46, 9.40). Trials with greater methodologic rigor and reporting transparency were associated with a more conservative estimate of the effect, 2.42 [0.96, 6.10], compared with 28.69 [5.08, 162.06] for less rigorous and poorly reported trials (P = 0.013 for the difference).


Busy clinicians may use simple educational interventions to increase the completion rate of advance directives documenting patient preferences for cardiopulmonary resuscitation. Understanding the influence of these interventions on other clinically important outcomes is worthy of further research.

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Patel, R., Sinuff, T. & Cook, D. Influencing advance directive completion rates in nonterminally ill patients: a systematic review. Crit Care 7 (Suppl 2), P254 (2003).

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