advance directives: assessing stage of change and decisional balance in a community-based...

Advance Directives: Assessing Stage ofChange and Decisional Balance in a

Community-Based Educational Program

Louis J. Medvene1 andMichelle Base

Wichita State University

Renee PatrickParsons State Hospital and

Training CenterParsons, KS

JoVeta WescottKansas Parish Nursing Ministry

Wichita, KS

This study assessed the applicability of the transtheoretical model (TTM) tocompleting/revising advance directives (ADs). Participants in a community-basededucational program completed pre- and post-program questionnaires concerningthe completing/revising of ADs. Multiple-item scales were constructed to categorizeparticipants into a stage of change: precontemplation (8%), contemplation (44%),preparation (4%), action (22%), and maintenance (19%). A decisional balance scalewas constructed using 5 positive and 5 negative perceptions of ADs. The findingsprovided support for the applicability of the TTM to completing/revising ADs. Thecons outweighed the pros among participants in the precontemplation stage, whilethe pros outweighed the cons among those in the action stage. One pro was that anAD would relieve family members of decision-making burdens.

The Terri Schiavo case dramatized the need to complete an advancedirective in a way that was both instructive and tragic. It was instructiveinsofar as it illustrated how the absence of an advance directive created astate of affairs that allowed a family conflict to escalate beyond the point ofamicable resolution. It was tragic insofar as her husband and her parentswere never able to agree about whether she would have wanted to be keptalive indefinitely using a respirator and feeding tubes.

Public interest and requests for advance directives have increased in theimmediate aftermath (Colby, 2005). However, given that planned interven-tions have only increased rates of completing/revising advance directives byan average of 10% (Miles, Koepp, & Weber, 1996), the Schiavo case may nothave a large impact on completion rates.

1Correspondence concerning this article should be addressed to Louis J. Medvene, Depart-ment of Psychology, Wichita State University, Box 34, Wichita, KS 67260-0034. E-mail:[email protected]

2298

Journal of Applied Social Psychology, 2007, 37, 10, pp. 2298–2318.© 2007 Copyright the AuthorsJournal compilation © 2007 Blackwell Publishing, Inc.

mailto:[email protected]

The reasons for people’s reluctance to complete advance directives arepoorly understood (Miles et al., 1996). One goal of the present study is toincrease understanding of attitudes and behaviors regarding the completionof advance directives in the context of a community-based educationalprogram. This study investigates the applicability of two important con-structs from the transtheoretical model (TTM) of behavior change—stages ofchange and decisional balance—to the rates of completing/revising advancedirectives. Demonstrating the applicability of these constructs to the case ofadvance directives could document the generalizability of the TTM modeland inform future educational campaigns.

Advance Directives

Completing advance directives has been a goal of federal health policysince the passage of the Patient Self-Determination Act (PSDA) in 1990. ThePSDA requires healthcare institutions to inform patients, on admission, oftheir right to provide information about their wishes for medical care shouldtheir decision-making capacity be lost at a future time.

Advance directives (ADs) are legal documents that allow individuals toexpress their medical treatment wishes in advance of serious illness, enablingthem to maintain control over medical decisions, even when they are unableto speak for themselves. ADs were developed, in part, to provide a legal basisfor ending curative treatment and for providing palliative care when deathappears to be imminent, and curative treatment is judged to be futile. Thereare two common types of ADs: (a) a living will, which instructs others aboutindividuals’ preferences regarding whether they want heroic, life-sustainingmeasures (e.g., transfusion, cardiopulmonary resuscitation) to be used in theevent that they become terminally ill, unable to speak for themselves, anddeath appears to be imminent; and (b) durable power of attorney for health-care decisions, which appoints proxy decision makers who have legal author-ity to make decisions regarding the use of life-sustaining measures on thepatient’s behalf if patients become unable to speak for themselves.

States vary regarding the types of instructional ADs they have enacted.Some states, like Kansas, have enacted living-will legislation that is relativelynarrow and vague, and asks individuals to indicate whether they wish toforgo life-sustaining procedures when such procedures would only prolongthe dying process. Other states, like Florida, have enacted a broader type ofinstructional AD or living will. The program, known as Five Wishes, asksindividuals to clarify their beliefs about quality of life and their values.

Since the passage of the PSDA, it is estimated that only 15% to 20% ofpersons have completed an AD (Crane, Wittink, & Doukas, 2005; Miles

ADVANCE DIRECTIVES 2299

et al., 1996). Older people, and people with terminal illness, are much morelikely to have begun advance planning or to have ADs, with more than halfof the people in these groups having completed the advanced planningprocess (The SUPPORT Investigators, 1995).

Despite many documented interventions (Miles et al., 1996; Patel, Sinuff,& Cook, 2004), little is known about reasons for noncompletion. There aresome data that show elderly individuals are reluctant to complete ADsbecause they believe that ADs are “too binding” and will reduce flexibilityregarding treatment options in a complex medical system (Beck, Brown,Boles, & Barrett, 2002). Beck et al. also found that elderly noncompletersbelieved ADs were unnecessary because their physicians and family membersalready knew their preferences. Individuals may also fear that they will not beable to accurately forecast their emotional reactions to terminal illness.

Individuals may be reluctant to complete an AD, at a time when they arehealthy, out of concern that the treatment preferences they specify in theirADs will be more limited than what their treatment preferences will actuallybe in an end-of-life situation. AD research (Tonnelli, 1996), as well as socialpsychological research (Gilbert, Pinel, Wilson, Blumberg, & Wheatley, 1998),suggests such concerns may have some validity. Additionally, clinicalresearch has documented that physicians are reluctant to discuss ADs withpatients (Morrison, Morrison, & Glickman, 1994), and they sometimes fail tohonor patients’ treatment wishes for palliative care at the end of life (Tenoet al., 1997). There is also general societal discomfort with thinking aboutand addressing death and dying (Miles et al., 1996).

Despite such doubts and limitations, there is good evidence that ADs arehelpful. Research has demonstrated (Rosenfeld, Wenger, & Kagawa-Singer,2000; Tilden, Tolle, Nelson, & Fields, 2001) that surrogates for patients withADs experienced less stress of decision making. Knowing patients’ AD pref-erences reduced the burden for family members who had the responsibility ofmaking decisions about ending treatment. Additionally, several interventionstudies in nursing-home settings have documented success in having residentsand family members complete ADs (50% rates of signing and higher) andhaving them widely implemented. In these studies, limited and valuablehealth resources were conserved with no reduction in satisfaction or in-crease in mortality (Molloy et al., 2000; Tolle, Tilden, Nelson, & Dunn,1998).

While Molloy et al.’s (2000) and Tolle et al.’s (1998) studies involved theuse of highly specific medical order forms that reflected residents’ treatmentpreferences and had more flexibility and options than do many living-willdocuments, the results of these studies illustrate the usefulness of advancecare planning. In general, all of this research indicates the potential benefitsof ADs and justifies the need for educational programs that increase rates of

2300 MEDVENE ET AL.

completion, as well as research that promotes understanding of the public’sattitudes toward completing ADs.

A Community-Based Educational Campaign

Hammes and Rooney’s (1998) community-based program, which resultedin an 85% completion rate, serves as a model for the present research. Theseresearchers trained people who functioned as Advance Care Planners (ACPs)in churches and community groups. The present research was conducted aspart of an effort to evaluate the effectiveness of an educational campaign topromote the discussion and completion of ADs in faith communities. Thisprogram, which is described more fully elsewhere (Medvene, et al., 2003),was organized by a community coalition that included the manager of aparish nursing program, the executive director of an interfaith organization,the executive director of a health ethics educational organization, and twouniversity professors.

The research data presented here are from the fourth year of the program.During this year, four congregations participated. The program included arecruitment meeting held at each congregation during October 2001, at whicha 15-min videotape introducing ADs was shown. All attendees completed apre-program questionnaire. Attendees who decided to participate were givena 32-page educational workbook informing them about common life-threatening illnesses, treatment options, and how ADs can facilitate end-of-life decision making. Attendees were invited to a meeting 1 month later atwhich the workbook was reviewed.

Parish nurses followed participants for a 5-month period and providedinformational support and emotional encouragement as appropriate. Partici-pants were asked to complete a post-program questionnaire in March 2002,indicating whether they had completed/revised an AD, as well as whetherthey had discussed ADs with their spouses, read the workbook, and hadcontact with an ACP (i.e., parish nurse).

Transtheoretical Model: Stages of Change

The TTM was used as a way to conceptualize and measure participants’initial readiness to complete/revise an AD, as well as the motivational factorsthat promoted or inhibited their completion/revision. The TTM is a modelfor behavior change that focuses on the individual’s decision making. Themodel has been applied to cases in which people are trying to discontinue aproblem behavior (e.g., smoking, alcohol abuse; Prochaska & DiClemente,


1983; Prochaska, DiClemente, & Norcross, 1992; Prochaska & DiClemente,1985; Prochaska, DiClemente, Velicer, & Rossi, 1993; Prochaska, Velicer,Guadagnoli, Rossi, & DiClemente, 1991) or to acquire a positive behavior(e.g., exercise adoption, using sunscreen; Prochaska, 1993; Prochaska et al.,1993; Prochaska et al., 1994; Velicer, Prochaska, Fava, Norman, & Redding,1998).

The present study is one of the first empirical applications of the TTMtheory to ADs, although at least one theoretical article has explored how thestages of change model might be applied to the case of ADs. Robbins,Levesque, Redding, Johnson, and Prochaska’s (2001) demonstration of theapplicability of the TTM to the case of family members’ decision makingfor consenting to organ donation is the most relevant of past empiricalresearch.

The TTM model suggests that in attempting to change behavior, peoplepass through a series of definable stages: precontemplation, contemplation,preparation, action, and maintenance (Prochaska et al., 1992). In the precon-templation stage, individuals typically do not intend to make the requisitebehavioral change in the near future (within 6 months). In the contemplationstage, people acknowledge that they need to make a behavioral change andbegin to think about how to do this. Individuals in the preparation stage areusually preparing to take action or make behavioral changes in the nextmonth. Action is the stage in which behavioral change is made and individu-als modify some aspect of their lives. Finally, maintenance is the stage inwhich individuals work to maintain their behavioral gains. Progress throughthe stages is often cyclical, as opposed to linear, and many people cycle backto an earlier stage of change prior to changing the target behavior.

A goal of the present study is to test the applicability of the stage ofchange concept to the case of ADs. It is expected that it will be possible tocreate a set of behavioral items that can be used to categorize participantsinto one of five stages of change regarding signing/revising ADs.

The TTM postulates a decisional balance sheet of benefits and costs as aschema underlying both the cognitive and motivational aspects of humandecision making. The decisional balance construct is based on Janis andMann’s (1977) model of decision making. A series of empirical studiesresulted in a two-factor model of decisional balance: the ratings of the posi-tive aspects of a decision (i.e., pros), and the ratings of the negative aspects ofa decision (i.e., cons; Prochaska et al., 1994). Robbins et al. (2001) alsoreported a two-factor model of decisional balance in their study of organdonation.

Given the poorly understood nature of people’s reluctance to sign ADs, asecond goal of the present study is to test the applicability of the decisionalbalance construct to the case of ADs. Of specific additional interest is

2302 MEDVENE ET AL.

whether the pros and cons will be limited to self-interest items or will alsoinclude concerns about the welfare of significant others. On the one hand, thePSDA legislation is based on individual patients’ rights to autonomy andcontrol regarding medical decision making (Jecker, 1990). This suggests thatthe primary psychological motivation for signing an AD would be the indi-vidual’s desire to maintain control and autonomy. On the other hand, theclinical ethics literature also includes a communitarian argument that theinterests of family members and intimate others are a legitimate basis for law(Blustein, 1993; Hardwig, 1990). In addition, family- and relationship-centered advance care planning interventions are being developed (Briggs,2004; Romer & Hammes, 2004). Of interest in the present study is exploringthe extent to which participants are motivated to sign/revise ADs by concernsfor the welfare of their family and loved ones, as well as by their desire tomaintain their autonomy and control over decisions about end-of-lifemedical treatments made on their behalf.

A final goal of this study is to explore the usefulness of the TTM as a guidefor educational intervention. Motivational interventions tailored to specificstages of change have been used, in combination with the TTM model, tohelp reduce alcohol use and smoking (Colby et al, 1998; Miller & Rollnick,1991). In the present study, if congregants were in the contemplation stage,parish nurses were instructed to engage them emotionally and intellectuallyby encouraging them to read the workbook. If congregants were in thepreparation or maintenance stage, parish nurses were instructed to encouragecongregants to think concretely and behaviorally about creating circum-stances that would be conducive to having a family discussion aboutADs.

In summary, the goals of the present study are to test the applicability ofthe TTM to the case of ADs. The study tests the reliability of behavioralitems developed to categorize people into one of five stages of change, as wellas the reliability of a set of items developed to characterize the pros ofcompleting/revising ADs and a set of items developed to characterize thecons of completing/revising ADs. The study also tests two hypotheses aboutthe construct validity of the decisional balance scale:

Hypothesis 1. The cons will outweigh the pros among partici-pants closest to the precontemplation stage, while the pros willoutweigh the cons among participants closest to the actionstage.

Hypothesis 2. The pros will be significantly higher among par-ticipants who complete/revise an AD versus those who do notsign/revise an AD.


Method

Participants

Study participants (n = 97; 57 female, 40 male) ranged in age from 34 to 91years (M = 57.7 years SD = 14.73 years). Of the participants, 74% weremarried. In terms of ethnicity, 96% were Caucasian, and the number of yearsof education ranged from 8 to 22 (M = 14.91, SD = 2.69). The participantswere recruited from four churches in a midsized city in the Midwest, witheach church representing a different denomination: Presbyterian, Methodist,Lutheran, and Catholic.

Procedure

The community coalition developed a program to train a small group ofparish nurses in each congregation to function as advance care planners(ACPs). Parish nurses were appropriate ACPs because they are registeredprofessional nurses whose mission focuses on empowerment and emphasizesindividual responsibility for health (Weis, Matheus, & Schank, 1997).2 Faithcommunities were an appropriate intervention site, given that religious insti-tutions offer congregants rich systems of belief and meaning for coping withillness, loss, and death and that large numbers of people are active in faithcommunities. Faith communities have been shown to be effective and acces-sible sites for health-promotion and illness-prevention programs (Pargament& Maton, 2000; Resnicow, Jackson, Want, Dudley, & Baranowski, 2001).

A university Institutional Review Board reviewed and approved theresearch protocol before the program began. Congregants from each churchwere invited to attend a recruitment meeting for an educational program tobe held in their congregation during the month of October 2001. Theprogram, entitled “Caring From Generation to Generation,” was intended toinform and educate congregants about the issue of ADs within the state ofKansas (Medvene et al., 2003).

At the recruitment meeting, congregants watched a 15-min video(Hammes & Rooney, 1993), which introduced the topic of ADs. The videopresented the experiences of several families who had experienced end-of-lifeheathcare decision making, or who had made healthcare planning decisions.All attendees were informed that there was a research component to theprogram and were asked to complete a pre-program questionnaire, the last

2There are approximately 7,000 parish nurses in the United States (D. Patterson, ExecutiveDirector of the International Parish Nurse Research Center, personal communication, February15, 2005).

2304 MEDVENE ET AL.

item of which asked whether they were going to participate in the program.Congregants who decided to participate were given the 32-page educationalworkbook about ADs as resource information (Pearlman et al., 1994).

The workbook and the “Caring” program focus on two types of ADs: aliving will and a durable power of attorney for healthcare decisions. Theliving will is the instrument that was enacted by the Kansas State Legislatureand asks individuals to indicate whether they wish to forgo life-sustainingprocedures when such procedures would only prolong the dying process.

The congregants who decided to participate were invited to an educa-tional meeting that was held 1 month later. During the educational meeting,an expert in ADs reviewed the workbook and answered participants’ ques-tions. All participants were informed that they would be asked to complete aquestionnaire when the program ended.

Participants were followed for a 5-month period because priorcommunity-based interventions had established that people frequently takeseveral months to make AD decisions (Clarke, Evans, Shook, & Johanson,2005). As noted earlier, parish nurses were given feedback about each par-ticipant’s stage of change and were asked to contact participants after theeducational meeting. If participants were in the contemplation stage, parishnurses were instructed to engage them emotionally; and if participants werein the preparation or maintenance stage, parish nurses were instructed toengage them concretely and behaviorally. Participants were encouraged todiscuss ADs with their family members and to make a decision about com-pleting a directive any time they felt ready. During the fifth month of theprogram (March 2002), we asked each participant to complete a post-program questionnaire that asked whether they had discussed ADs with theirspouses had read the workbook, had contact with an ACP, and had signed orrevised an AD document.

Materials

The pre-program questionnaire includes items that categorize partici-pants into one of five stages of change, depending on the participant’s currentattitude and intentions regarding signing/revising an AD. Three-item scaleswere developed for each of the following stages: precontemplation, contem-plation, and preparation. Sample items are “As far as I’m concerned, I don’tneed an AD” (precontemplation); “I’ve been thinking I might want to sign anAD” (contemplation); and “I’ve set aside time to talk about ADs during thenext few weeks” (preparation). Scale items are presented in Table 1.

Participants indicated the extent to which they agreed with each attitudi-nal item on a 5-point Likert-type scale ranging from 1 (strongly disagree) to5 (strongly agree). A score was calculated for each participant for each of the


three scales (i.e., precontemplation, contemplation, and preparation). Par-ticipants were categorized as being in the stage of change for which their scalescore was highest.3 Cronbach’s alphas for precontemplation, contemplation,and preparation, were .93, .78, and .81, respectively.

3Of the 103 participants who completed the pre-program questionnaire, 3 had equivalentmeans for three or more stages. We excluded the data of these 3 participants. Data from 3 of the100 remaining cases were excluded from analysis because they were missing information regard-ing the pros and cons. Of the remaining 97 participants, 5 had equivalent means for two stages.We resolved these ties by alternately assigning each participant to a prior stage (e.g., we assigned

Table 1

Items Used to Categorize Participants Into Stage of Change Regarding Signingan Advance Directive (AD)

a

Precontemplation items .931. As far as I’m concerned, I don’t need an AD.2. I don’t have an AD, and right now I don’t care.3. I am satisfied not having an AD.

Contemplation items .781. I’ve been thinking I might want to sign an AD.2. I’ve been thinking whether I am able to sign an AD.3. I’ve been thinking that I may want to begin discussing ADs.

Preparation items .811. I’ve been talking about the need to set aside time to discuss

signing ADs within the next few weeks.2. I’ve set up a day and time to discuss and sign an AD within the

next few weeks.3. I’ve set aside time to talk about ADs during the next few weeks.

Action itemI have completed an AD. (Yes/No)

Maintenance item (i.e., has already signed an AD)I am interested in revising my AD. (4 or 5 on a 5-point scaleregarding interest in revising AD)

Note. The precontemplation, contemplation, and preparation items were rated on a5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). The maintenanceitem was rated on a 5-point scale ranging from 1 (not interested) to 5 (very interested).

2306 MEDVENE ET AL.

Participants who had completed an AD prior to participating in theprogram (n = 41) were asked about their agreement with the statement “I aminterested in revising my AD.” Participants indicated their agreement on a5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Partici-pants were categorized as being in the action stage if they had little interest inrevising their ADs (i.e., their answers ranged from strongly disagree toneutral; 1, 2, or 3 on the 5-point scale). Participants were categorized as beingin the maintenance stage if they were interested in revision (i.e., their answerswere agree or strongly agree; 4 or 5 on the 5-point scale).

The pre-program questionnaire also includes 10 items to assess the prosand cons (5 pros, 5 cons) of signing an AD. The items were developed basedon a review of the literature, input from parish nurses who had participatedin the first 3 years of the “Generation to Generation” program, expert judg-ments of staff of the partnering health ethics organization, and data fromfocus groups of congregants conducted prior to introduction of the educa-tional program in 1997 (Medvene, Wescott, Huckstand, Ludlum, & Langel,2000). The pool of items from which the final 10 items were selected includesitems representing self-interest, as well as concern for the interests of signifi-cant others (Janis & Mann, 1977). Pro and con items are listed in Table 2.Cronbach’s alphas for the pro and con scales were .82 and .75, respectively.The sums of the pros and the cons were negatively correlated (r = -.41,p < .01).

The post-program questionnaire includes items about whether partici-pants had, as a result of the program, revised an AD that had been signedprior to the program or signed an AD for the first time. Of the 97 participantswho had completed a pre-program survey, 33 (34%) also completed a post-program survey.

Results

Based on their responses, the 97 participants were assigned to stages asfollows: precontemplation, n = 8; contemplation, n = 44; preparation, n = 4;action, n = 22; and maintenance, n = 19. The mean for the pro scale was 3.94(SD = 0.66), based on the average of the five items on a 5-point scale

a participant to the precontemplation stage if he or she had equal means for the precontempla-tion and contemplation stages) or to a later stage (e.g., in the next case, we assigned theparticipant to the contemplation stage if he or she had equal means for the precontemplation andcontemplation stages). So, ties for 3 participants were resolved by categorizing the participantsin a stage that was more removed from action (i.e., from preparation to contemplation), and tiesfor 2 participants were resolved by categorizing the participants in a stage closer to action (i.e.,from precontemplation to contemplation).


(a = .82). The mean for the con scale was 2.27 (SD = 0.72), also based on theaverage of the five items on a 5-point scale (a = .75).

Regarding the question as to whether participants were motivated tosign/revise ADs out of concern for family welfare, as well as by a desire tomaintain individual autonomy, Table 2 presents the means for each of thepro and con items. Of the five pro items, three (Items 1, 2, and 5) refer to

Table 2

Pro and Con Items Regarding Advance Directives (ADs)

“By signing an AD now . . .” a M SD

Pro items .821. I will relieve my family of any future burden of having

to make difficult medical decisions on my behalfwithout knowing my wishes.

4.00 0.94

2. I will be taking care of something that is really myresponsibility (as a spouse, etc.) to my family.

4.07 0.89

3. I will have more control over the kind and type ofmedical care I will receive should I become critically ill.

3.88 0.85

4. I will be able to maintain the quality of life I desire tillthe end of my life.

3.88 0.84

5. I will be sparing my family some possible financialburden in the future if I should become terminally ill.

3.90 0.83

Con items .751. Discussions with my family around ADs will make

them uncomfortable.2.51 1.14

2. If I sign an AD now, I’m afraid it would be used todeny me medical care in the future if I were to becomecritically ill.

2.24 1.04

3. If I sign an AD now, I might change my mind aboutwhat I want—given different circumstances—and bestuck with my AD.

2.39 1.06

4. It is not necessary for me to sign an AD because myfamily will know what to do when the time comesanyway.

2.24 1.09

5. At this stage of my life, I really don’t need an AD yet. 2.06 0.88

Note. Scores ranged from 1 to 5. Higher scores indicate stronger endorsement of theitems.

2308 MEDVENE ET AL.

motivations regarding family welfare, and two (Items 3 and 4) refer tomaintaining individual autonomy. As can be seen, participants endorsed thefamily-welfare items as strongly as they endorsed the individual-autonomyitems.

A test of the construct validity of the decisional balance scale was to assesswhether participants in the precontemplation stage (i.e., furthest from theaction or maintenance stages) would endorse the cons more strongly than thepros, while participants in the action and maintenance stages would endorsethe pros more strongly than the cons. In order to carry out this test, wecreated a standard metric: Each pro and con item was converted to a stan-dard score and then to a t score (M = 50, SD = 10). Table 3 illustrates themeans and standard deviations for the sum of the average of the t scores forthe pro items, and the sum of the average of the t scores for the con items bystage of AD signing.

The results of a MANOVA with stage of change as the independentvariable and the sums of the means of the t scores for pros and cons as thedependent variables are summarized in Table 3. The results are consistentwith the hypothesis that participants would endorse the con items morestrongly the further removed they were from the action or maintenancestages, and would endorse the pro items more strongly the closer they were tothe action or maintenance stages. This effect was stronger for the pros thanfor the cons, F(4, 92) = 14.91, p < .01, h2 = .36 (for pros); and F(4, 92) = 5.77,p < .01, h2 = .16 (for cons). Figure 1 illustrates the association between stageof change and strength of endorsement of the pros and cons.

The association between the decisional balance scale and stage of changewas tested in another manner. A summary decisional balance measure wascreated by subtracting the sum of the means of the con t scores from the sumof the means of the pro t scores. A minus sign indicates that the sum of thecons was higher than the sum of the pros; while a positive sign indicates thatthe sum of the pros was higher than the sum of the cons.

To examine the strength of the association between stage of change andscores on the decisional balance scale, an ANOVA was conducted with stageas the independent variable and decisional balance as the dependent variable.Results of this analysis were significant, F(4, 91) = 13.92, p < .01, h2 = .35.Using Tukey’s honestly significant difference (HSD) for post hoc compari-sons, participants in the contemplation (M = -1.07, SD = 10.02), preparation(M = -0.55, SD = 13.29), action (M = 7.89, SD = 8.58), and maintenance(M = 4.13, SD = 10.44) stages had significantly higher decisional balancescores ( p < .05) than did participants in the precontemplation stage(M = -22.79, SD = 13.40). Participants in the action stage also had signifi-cantly higher decisional balance scores ( p < .05) than did participants in thecontemplation stage.


Tab

le3

Sta

ndar

dS

core

(tS

core

)M

eans

ofA

vera

geof

Pro

Item

and

Ave

rage

ofC

onIt

emS

cale

sby

Sta

geof

AD

Sig

ning

PC

(n=

8)C

(n=

44)

P(n

=4)

A(n

=22

)M

(n=

18)

FT

ukey

’sH

SDh2

MS

DM

SD

MS

DM

SD

MS

D

Pro

item

s35

.97

12.0

049

.53

5.07

49.8

99.

7755

.29

5.09

50.7

95.

1814

.57*

C,P

,A,

M>

PC

;A>

C.3

6

Con

item

s58

.77

7.39

50.6

16.

2250

.45

7.10

47.4

06.

4146

.65

6.12

6.04

*P

C>

C,A

,M.1

7

Not

e.A

D=

adva

nce

dire

ctiv

e;P

C=

prec

onte

mpl

atio

n;C

=co

ntem

plat

ion;

P=

prep

arat

ion;

A=

acti

on;

M=

mai

nten

ance

;H

SD=

hone

stly

sign

ifica

ntdi

ffer

ence

.*p

<.0

1.

2310 MEDVENE ET AL.

A second check of the construct validity of the decisional balance scaleinvolved testing the hypothesis that participants who signed/revised an AD(as opposed to participants who had not signed/revised) would endorse thepro items more strongly than the con items. A one-way ANOVA was con-ducted with signing status (i.e., signed/revised an AD vs. not doing so) as theindependent variable and the decisional balance scale score as the dependentvariable. The main effect for signing status was significant, F(1, 30) = 14.96,p < .001, h2 = .32. Participants who signed/revised an AD had higher deci-sional balance scores than did participants who did not sign/revise an AD(Ms = 31.70 and -20.90, respectively).

A goal of the educational program was to move participants towardaction. To assess the extent to which this happened, a descriptive analysis wasconducted using data from the 33 participants who completed post-programquestionnaires. The 15 participants who signed or revised ADs were distrib-uted as follows: 1 of the 8 participants in the precontemplation stage signedan AD (12%); 5 of the 44 participants in the contemplation stage signed anAD (11%); 1 of the 4 participants in the preparation stage signed an AD(25%); 3 of the 22 participants who had signed an AD prior to the programbut who initially had expressed little interest in revision did, in fact, revisetheir ADs (13%); and 5 of the 19 participants who had signed an AD prior tothe program and initially had expressed interest in revision did, in fact, revisetheir ADs (26%).

Also of interest was whether stage of change was related to whetherparticipants discussed ADs with their spouses, read the workbook, or hadcontact with the ACPs. Virtually all of the participants (92%) had discussed

30354045505560

Preco

ntem

platio

n (n

=8)

Conte

mpla

tion

(n=4

4)

Prepa

ratio

n (n

=4)

Action

(n=2

2)

Main

tena

nce

(n=1

8)

Stage of Change

Sta

nd

ard

Sco

res

Pro

Con

Figure 1. Pros and cons of signing advance directives by stage of change.


ADs with their spouses. In addition, 87% of participants read the workbook,and this was unrelated to stage of change: c2(4, N = 33) = 4.20, ns. Havingcontact with the ACP was related to stage of change, c2(4, N = 28) = 15.29,p < .004. All of the participants in the action and maintenance stages hadcontact with the ACP, with smaller percentages having contact in the stagefurther from action (preparation, 50%; contemplation, 39%; and precontem-plation, 0%). Overall, 62% of participants had contact with an ACP.

Exploratory analyses were also conducted relating participants’ demo-graphic characteristics to their stage of change and decisional balance. AnANOVA with stage of change as the independent variable and age as thedependent variable resulted in a significant association, F(4, 94) = 11.83,p < .01. Post hoc analyses using Tukey’s HSD resulted in significant differ-ences ( p < .05) between participants in the action and maintenance stages(M = 69.30, SD = 15.93; and M = 66.66, SD = 12.23, respectively), who wereolder than participants in the precontemplation, contemplation, and prepa-ration stages (M = 49.75, SD = 9.25; M = 51.04, SD = 10.85; and M = 50.25,SD = 12.44, for precontemplation, contemplation, and preparation, respec-tively). Age was also correlated with decisional balance (r = .21, p < .05),indicating that older participants were more likely to endorse the pros ofsigning an AD more strongly than the cons. Age was not related to whetherparticipants signed/revised an AD, F(1, 30) = .009, ns. None of the otherdemographic variables were found to be significantly associated with eitherstage of change or decisional balance.

Discussion

The present findings provide preliminary support for the applicability ofstages of change and decisional balance constructs to completing/revising anAD. It was possible to categorize participants into distinctive stages ofchange, as well as to construct reliable and valid summary measures of theirpros and cons. However, some of the findings raise questions about how wellthe TTM model fits the process of completing an AD.

Fit Between TTM Model and ADs

Questions of fit are raised by the findings that there was little differencebetween participants in the contemplation and preparation stages (in termsof their scores on the pros and cons scales) and that similar percentages ofparticipants at each stage of change completed/revised ADs. Perhaps com-pleting ADs is more of a single event than a dynamic behavior change

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process. The small number of participants in the precontemplation andpreparation stages makes it difficult to draw conclusions about fit. Futureresearch with larger, more representative samples would provide a necessaryempirical test of the question of fit.

On a conceptual level, it might be argued that the TTM model does notseem to fit ADs because the action and maintenance stages appear to beone-time behaviors, rather than ongoing behavioral change processes.Viewing advance care planning as a legalistic and document-driven process isconsistent with the idea that completing or revising an AD is a one-timebehavior (Miles et al., 1996). However, advocates of ADs have developedand used AD documents that focus more broadly on patients’ definitions ofquality of life and on their values. These advocates promote an advance careplanning process that involves ongoing discussions between patients andtheir physicians, and between patients and their surrogates (Crane et al.,2005; Pearlman, Starks, Cain, & Cole, 2005; Romer & Hammes, 2004).Advance care planning that uses broadly instructive ADs likely encouragesindividuals to engage in a more dynamic process, which fits the TTM modelbetter and results in better outcomes. This hypothesis should be tested infuture research.

Stages of Change

The questionnaire items used to categorize participants into stages con-stituted reliable scales. Future studies could explore the extent to which singleitems or an algorithm would do just as well in categorizing participants intostages. Regarding generalizability, the findings that 42% of participants hadan AD prior to the program and 45% were contemplating completing an ADwhen the program began are probably not widely generalizable. These find-ings are likely typical of samples in studies in which participants have selectedthemselves into educational programs such as the “Generation to Genera-tion” program.

Compared to most studies of AD interventions, a 45% rate of completion/revision is very high. However, most intervention studies have been con-ducted with more representative samples—for example, patients in a healthmaintenance organization practice (Miles et al., 1996)—in which most par-ticipants were likely in the precontemplation stage.

Decisional Balance Scale

The present findings support the idea that decisional balance is usefullyconceptualized and measured in terms of a two-factor solution: pros andcons. The findings replicate previous two-factor solutions with regard to the


target behaviors of smoking cessation and organ donation (Prochaska et al.,1994; Robbins et al., 2001).

A limitation of the decisional balance scale that was developed here is thatthe pro and con scales were more strongly correlated than is desirable. Futureresearch should be conducted using a large pool of pro and con items. Suchresearch could produce an expanded version of the present scale in which thepro and con measures would be more independent. An expanded version ofthe pro and con items could also produce scales that differentiate moreclearly between people in the preparation, action, and maintenance stages.Despite these limitations, it should be noted that the decisional balance scalewas a better predictor of completing/revising ADs than was the importantdemographic of age (Miles et al., 1996).

More specifically, the present findings contribute to understanding peo-ple’s motives for completing/revising ADs. The finding that participants weremotivated to complete/revise ADs out of concern for their family members,thus relieving them of decision-making and financial burdens, is new. Previ-ous ethics literature regarding ADs has focused on the motives and legiti-macy of maintaining patient agency and autonomy. If the present findingsare replicated, future educational campaigns might use this information toappeal to participants on the basis of their concern for family members.However, it is possible that participants in the current study endorsed family-welfare items out of social desirability concerns. The present findings must beconfirmed by other research conducted in nonreligious settings where altru-istic norms might be less salient.

The content of the con items is especially important here. The moststrongly endorsed items were ones that have been identified in recent research(Crane et al., 2005; Fagerlin & Schneider, 2004). Of relevance here are indi-viduals’ concerns that “If I sign an AD now, I’m afraid it would be used todeny me medical care in the future if I were to become critically ill” and “IfI sign an AD now, I might change my mind about what I want—givendifferent circumstances—and be stuck with my AD.” Identifying these con-cerns will contribute to our understanding of people’s reluctance to completeADs.

Limitations and Future Research

Stronger evidence is needed to establish that the decision to complete/revise an AD is better characterized by a stage model than by a continuummodel (Weinstein, Rothman, & Sutton, 1998). With regard to futureresearch, the decisional balance measure created here promises to contri-bute to the development of motivational interventions that are tailored to

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participants’ stage of change (Briggs, 2004; Westley & Briggs, 2004). Whilethe Schiavo case alerts us to the need for ADs, the present findings indicatethat we have a distance to go before AD documents are developed thatpeople will feel comfortable completing and ACP processes that people willfind compelling.

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