• Terri R Fried, Karen Bullock, Lynne Iannone, and John R O'Leary.
• Department of Medicine, School of Medicine, Yale University, New Haven, Connecticut, USA. terri.fried@yale.edu
• J Am Geriatr Soc. 2009 Sep 1;57(9):1547-55.

ObjectivesTo explore whether models of health behavior change can help to inform interventions for advance care planning (ACP).DesignQualitative cross-sectional study.SettingCommunity.ParticipantsSixty-three community-dwelling persons aged 65 and older and 30 caregivers with experience as surrogate decision-makers.MeasurementsIn focus groups conducted separately with older persons and caregivers, participants were asked to discuss ways they had planned for future declines in health and why they had or had not engaged in such planning. Transcripts were analyzed using grounded theory.ResultsFour themes illustrated the potential of applying models of health behavior change to improve ACP. (1) Participants demonstrated variable readiness to engage in ACP and could be in different stages of readiness for different components of ACP, including consideration of treatment goals, completion of advance directives, and communication with families and physicians. (2) Participants identified a wide range of benefits of and barriers to ACP. (3) Participants used a variety of processes of change to progress through stages of readiness, and ACP was only one of a broader set of behaviors that participants engaged in to prepare for declines in their health or for death. (4) Experience with healthcare decision-making for loved ones was a strong influence on perceptions of susceptibility and engagement in ACP.DiscussionThe variability in participants' readiness, barriers and benefits, perceptions of susceptibility, and use of processes to increase readiness for participating in each component of ACP suggests the utility of customized, stage-specific interventions based on individualized assessments to improve ACP.

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