Our March Clinical Ethics Journal Club meeting was led by Dr. Eric Widera of the Division of Geriatrics, featuring an in-depth discussion of Halpern et al.’s paper, “Effect of Default Options in Advance Directives on Hospital-Free Days and Care Choices Among Seriously Ill Patients.” The authors gave patients advance directives that were randomly defaulted to different end-of-life treatment options, comparing comfort care to life sustaining, to determine if preselected choices or the deliberate ordering of choices impacted patients’ decisions on end-of-life care. They found that patients were more likely to select the care option that was defaulted to them in their directive, even after they were debriefed about the purpose of default options.
We used the paper to segue into a discussion about behavioral economics and choice architecture in the context of advance care planning, making note of how the use of preselected choices made us feel as clinicians who were well versed in the value of autonomy. We also more broadly discussed the purpose of advanced directives in advance care planning, acknowledging that our conversations with patients about end-of-life care can often create environments that influence the development of their values and decisions.