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Publication Briefs

Easy-to-Use Advance Care Planning (ACP) Tools Increase Planning among Older Veterans

The advance care planning (ACP) process involves a series of discussions over time in addition to the completion of an advance directive (AD). However, most older adults (even those with serious conditions) have not engaged in ACP, and patients' wishes are often not documented. Study investigators created the PREPARE website, which has been shown to empower older adults to engage in ACP through the use of a simple 5-step process and "how-to" videos. In addition, the team created an easy-to-read advance directive that has significantly increased patient documentation of ACP. The objective of this randomized clinical trial was to compare the efficacy of PREPARE plus the easy-to-read AD (PREPARE plus AD) vs. the AD alone (AD-only) to increase ACP documentation and engagement. Veterans aged 60 years and older with at least two chronic medical conditions (n=414) were enrolled from a women's, geriatrics, and several general medicine clinics at the San Francisco VAMC from April 2013 through July 2016. Two hundred and five Veterans were randomized to the PREPARE plus AD group, and 209 Veterans were randomized to the AD-only group. The primary outcome was new ACP documentation (i.e., legal forms and/or discussions) at 9 months. Secondary outcomes included patient-reported ACP engagement at 1 week, 3 months, and 6 months using validated surveys of behavior change process measures (i.e., knowledge, self-efficacy, readiness) and action measures (i.e., surrogate designation). Investigators also assessed patient characteristics, including demographics, health status, health literacy, and social support.


  • PREPARE plus an easy-to-read advance directive (AD) resulted in statistically significant higher advance care planning documentation (ACP) (35%) compared with an easy-to-read AD alone (25%).
  • PREPARE also resulted in higher self-reported ACP engagement at each follow-up, including higher process and action scores.
  • Both tools were rated highly in terms of ease-of-use, satisfaction, helpfulness, and the likelihood Veterans would recommend the guide to others.


  • Patient-facing advance care planning tools increased advance care planning documentation and engagement without additional clinician- or system-level interventions. This study suggests that PREPARE may increase advance care planning with minimal healthcare system resources.

    • Materials were viewed in study offices with computer access, potentially limiting generalizability to viewing at home.

    This study was partly funded by HSR&D (IIR 11-110). Dr. Sudore and Ms. Feuz are part of the San Francisco VA Medical Center.

    PubMed Logo Sudore RL, Boscardin J, Feuz MA, McMahan RD, Katen MT, Barnes DE. Effect of the PREPARE Website vs. an Easy-to-Read Advance Directive on Advance Care Planning Documentation and Engagement among Veterans: A Randomized Clinical Trial. JAMA Internal Medicine. August 1, 2017;177(8):1102-1109.

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