• Elizabeth Wickersham, Mary Gowin, Munim H Deen, and Zsolt Nagykaldi.
• From the Department of Family and Preventive Medicine, Research Division (EW, MG, ZN), Primary Care Health Policy Division (MG), Department of Biostatistics and Epidemiology, College of Public Health (MHD), University of Oklahoma College of Medicine, Oklahoma City, OK. elizabeth-wickersham@ouhsc.edu.
• J Am Board Fam Med. 2019 Mar 1; 32 (2): 168-179.

BackgroundOklahoma's Advance Directive completion rate is less than 10%. We compared the implementation performance of 2 advance directive forms to determine which form could be more successfully disseminated.MethodsThe implementation of the Oklahoma Advance Directive (OKAD) and the Five Wishes form were compared in an 8-month pair-matched cluster randomized study in 6 primary care practices. The outcomes measured during the 22-week implementation included form offering rate, acceptance/completion rate by patients, and documentation in the chart. Twenty semistructured interviews with patients and clinicians were conducted to assess intervention experience.ResultsA total of 2748 patient encounters were evaluated. OKAD was offered in 33% of eligible patient visits (493/1494) and accepted 54% of the time (266/493). Five Wishes was offered in 36% of eligible patient visits (450/1254) and accepted 82% of the time (369/450). Unadjusted analyses found no significant difference in offering of advance directive forms between groups. However, the odds of accepting Five Wishes were 3.89 times that of OKAD (95% CI, 2.88 to 5.24; P < .0001). Logistic regression models controlling for several confounders indicated that the acceptance of Five Wishes was favored significantly over OKAD (OR = 1.52; 95% CI, 1.27 to 1.81; P < .0001). Qualitative analyses indicated a clear clinician and patient preference for Five Wishes.ConclusionsResults suggest that Five Wishes was more readable, understandable, appealing, and usable. It seemed to capture patient preferences for end-of-life care more effectively and it more readily facilitated patient-clinician conversations.© Copyright 2019 by the American Board of Family Medicine.

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