Research Article
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Published Online: 11 March 2014

Respecting Choices® and Advance Directives in a Diverse Community

Publication: Journal of Palliative Medicine
Volume 17, Issue Number 3


Background: Respecting Choices® is a program designed and verified to improve advance care planning, yet it has not been tested in racially/ethnically diverse communities. Research has shown racial/ethnic minorities are less likely to have advance directives (ADs).
Objective: To determine whether Respecting Choices® would improve AD prevalence and utilization in a racially and ethnically diverse community.
Methods: The study design was that of a retrospective chart review. Subjects were all decedents from 2005 to 2010 (n=732) in a 300-bed Midwestern metropolitan hospital. Prevalence was assessed by the presence of an AD in the chart. Utilization was measured by the consistency of wishes expressed in an AD and treatment received (“No CPR,” “No Feeding Tube,” “No Antibiotics,” “No Ventilator,” “Comfort Care,” and “Terminal Extubation”). Average treatment effect using regression analysis and matching on covariates was used for analysis of Respecting Choices® on AD prevalence. Proportional difference tests were used to compare consistency of wishes by race/ethnicity before and after Respecting Choices®.
Results: The prevalence of ADs increased significantly for racial and ethnic minorities after the implementation of Respecting Choices®: from 25.8% to 38.4% (p=0.011). The increase in AD prevalence for whites following Respecting Choices® was only marginal (46.7% to 47.3%; p=0.648), and the overall prevalence of ADs did not significantly change (35.9% to 42.9%; p=0.069). Consistency was high (74% to 96%) for all orders, and there were no significant differences following implementation of Respecting Choices® or between whites and racial and ethnic minorities.
Conclusions: The prevalence of ADs increased after Respecting Choices® was initiated in a racially and ethnically diverse community.

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Published In

cover image Journal of Palliative Medicine
Journal of Palliative Medicine
Volume 17Issue Number 3March 2014
Pages: 282 - 287
PubMed: 24325558


Published online: 11 March 2014
Published in print: March 2014
Published ahead of print: 10 December 2013
Accepted: 1 November 2013


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    Kristen E. Pecanac
    University of Wisconsin-Madison School of Nursing, Madison, Wisconsin.
    Mark F. Repenshek
    Department of Ethics, Columbia St. Mary's Hospital, Milwaukee, Wisconsin.
    David Tennenbaum
    Department of Inpatient Medicine, Columbia St. Mary's Hospital, Milwaukee, Wisconsin.
    Bernard J. Hammes
    Gundersen Health System, La Crosse, Wisconsin.


    Address correspondence to:Kristen E. Pecanac, MS, RNSchool of NursingUniversity of Wisconsin-MadisonBox 2455 Clinical Science Center600 Highland AvenueMadison, WI 53792E-mail: [email protected]

    Author Disclosure Statement

    BJH is an employee of the Gundersen Health System, a not-for-profit organization dedicated to medical education and research that owns the copyrighted materials known as Respecting Choices referred to in this article and sells these materials and the related training. BJH is a coauthor of the Respecting Choices professional training materials and is entitled to a small royalty if and when a net profit is made on these materials.

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