Study of Default Options in Advance Directives
Study of Default Options in Advance Directives
Default options represent the events or conditions that are set into place if no alternatives
 are actively chosen. The setting of default options has well-established effects on a broad
 range of human decisions, but its influence on patients' preferences for end-of-life care is
 only beginning to be understood.

 This is a 3-armed randomized clinical trial in Veterans at high risk for critical illness,
 assessing the impact of Advance Directive (AD) forms framed with different default options.
 The central goals are to assess how default options in ADs influence the end-of-life care
 choices made by patients at risk for critical care, and these patients' hospital and ICU
 utilization.

 The investigators hypothesize that setting defaults in real ADs will increase the proportion
 of Veterans selecting comfort-oriented plans of care, decrease selections of life-extending
 therapies such as mechanical ventilation and dialysis, and reduce the proportion of time
 during follow-up that Veterans spend in the hospital and/or ICU, without affecting patient
 satisfaction with end-of-life care planning.
Inclusion Criteria:

 -  Age > 18 years

 -  Chronic Obstructive Pulmonary Disease (COPD) with severe or very severe airflow
 obstruction on pulmonary function testing and or receiving or eligible to receive
 long-term oxygen therapy AND/OR

 -  Idiopathic Pulmonary Fibrosis (IPF) AND/OR

 -  Other interstitial lung disease without curative therapy AND/OR

 -  Any stage 3B or 4 solid tumor AND/OR

 -  Congestive Heart Failure (CHF) either New York Heart Association NYHA) class IV or
 NYHA class III plus 1 hospitalization in the past year

 -  No previously signed advance directive in the medical record

 -  Neither listed for nor considering lung or heart transplantation

 -  High anticipated risk for critical illness in the next 2 years based on clinical
 judgment

 -  Interest in thinking about filling out an Advance Directive

 Exclusion Criteria:

 -  Diseases for which life-extending medical therapies may be available

 -  Inability to speak and/or read English proficiently

 -  New clinic patients meeting the clinic provider for the first time

 -  Patients being actively evaluated or already listed for transplants

 -  Patients already having an AD

 -  Cognitive impairment necessitating proxy consent