Strategies to promote the use of advance directives in a residency outpatient practice

To evaluate patient education and resident education strategies to promote advance directives in the outpatient setting, and to assess barriers to implementation. Controlled clinical trial. The internal medicine residents' practice of an urban, university medical center. Medical residents and 250 patients seen at least twice in the 3 months prior to the study. We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, and videotaping of an actual discussion by each resident, followed by individual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discuss advance directives. We interviewed 187 of these patients (response rate 75%) and surveyed 62 residents (response rate 70%). After 18 months, there were no significant differences in the number of advance directives in charts among the three groups. Documented advance directives discussions with patients in the resident education group increased from 3% to 17% (p < .001), more than those in the patient education (5%) or control group (10%, p = .04). Residents in the resident education group were more likely to report discussing advance directives than those in the patient education or control groups (p = .05). Lack of time (95%) and lack of continuity (76%) were the most frequently cited barriers. In multivariate logistic regression, nonwhite race and non-U.S. birth were negatively associated with patient interest in advance directives. Patient race and birthplace were not associated with actual discussions of advance directives. Even with intensive efforts to educate outpatients and residents about advance directives, important barriers remain, raising questions about how best to promote advance directives among outpatients.