brand logo

Am Fam Physician. 2018;98(11):682-683

Clinical Question

Does advance care planning lead to increased completion of advance directives and selection of surrogate decision makers among frail older adults?

Bottom Line

In this study, an intensive advance care planning intervention dramatically increased the completion of advance directives and the identification of surrogate decision makers. (Level of Evidence = 2b)


These researchers conducted a cluster randomized trial of facilitated advance care planning education or usual care among modestly frail older adults living in residential care homes or receiving home care nearby. The education intervention included trained facilitators and educational materials and tools intended to identify the patients' goals, values, and preferences regarding their health care and to assist in identifying a surrogate decision maker in the event of non-competence. In addition to assigning an activation score (not all that important), the researchers assessed whether the patients had documented their advance care preferences and had selected a surrogate decision maker. The researchers included 16 clusters that contributed 201 patients (between one and 53 patients per cluster). The patients in each group were in their mid-80s and most were female. The intervention patients were more likely to receive home-based care (61%) and to have completed high school (65%) than the control patients (49% and 40%, respectively). At the end of one year, 93% of the intervention group had completed an advance directive compared with 34% of control patients (number needed to treat [NNT] = 2; 95% confidence interval [CI], 2 to 3). Additionally, 94% of the intervention participants had identified a surrogate decision maker compared with 67% of the control patients (NNT = 4; CI, 3 to 6). The consultation sessions took an average of two hours, including travel time, to complete.

Study design: Randomized controlled trial (nonblinded)

Funding source: Foundation

Allocation: Unconcealed

Setting: Other

Reference: OverbeekAKorfageIJJabbarianLJet alAdvance care planning in frail older adults: a cluster randomized controlled trial. J Am Geriatr Soc2018;66(6):1089–1095.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to

This series is coordinated by Natasha J. Pyzocha, DO, contributing editor.

A collection of POEMs published in AFP is available at

Continue Reading

More in AFP

More in PubMed

Copyright © 2018 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.