A Randomized Controlled Trial of Strategies to Improve Family Members’ Preparedness for Surrogate Decision-Making

Objective: To evaluate 2 strategies for preparing family members for surrogate decision-making. Design: A 2 × 2 factorial, randomized controlled trial testing whether: (1) comprehensive online advance care planning (ACP) is superior to basic ACP, and (2) having patients engage in ACP together with family members is superior to ACP done by patients alone. Setting: Tertiary care centers in Hershey, Pennsylvania, and Boston, Massachusetts. Participants: Dyads of patients with advanced, severe illness (mean age 64; 46% female; 72% white) and family members who would be their surrogate decision-makers (mean age 56; 75% female; 75% white). Interventions: Basic ACP: state-approved online advance directive plus brochure. Making Your Wishes Known (MYWK): Comprehensive ACP decision aid including education and values clarification. Measurements: Pre–post changes in family member self-efficacy (100-point scale) and postintervention concordance between patients and family members using clinical vignettes. Results: A total 285 dyads enrolled; 267 patients and 267 family members completed measures. Baseline self-efficacy in both MYWK and basic ACP groups was high (90.2 and 90.1, respectively), and increased postintervention to 92.1 for MYWK (P =.13) and 93.3 for basic ACP (P =.004), with no between-group difference. Baseline self-efficacy in alone and together groups was also high (90.2 and 90.1, respectively), and increased to 92.6 for alone (P =.03) and 92.8 for together (P =.03), with no between-group difference. Overall adjusted concordance was higher in MYWK compared to basic ACP (85.2% vs 79.7%; P =.032), with no between-group difference. Conclusion: The disconnect between confidence and performance raises questions about how to prepare family members to be surrogate decision-makers.