Too many dying choices
Giving people too many choices can lead to a barrier in selection. The complexity and confusion involved with an array of options impedes the selection process and, therefore, a person’s ability to make a decision. Upon entering a restaurant, many patrons who are given their choice from the vast selection of empty tables to dine at have a difficult time deciding where to sit. The same applies if the menu has too many options to choose from. This lends itself to analysis paralysis. Two-thirds of US citizens do not complete an advance directive. A variety of barriers have contributed to this high percentage. These barriers include issues involving access to documents, as well as complicated legal and medical jargon. However, providing an overabundance of options can also be a hindrance to completing an advance directive.
The American Bar Association was the primary source for the compilation of advance directives and living wills from all 50 states and the District of Columbia. Each document was analyzed for options provided in the living will portion of the document. Choices were identified as selections providing unique changes to end-of-life treatment or care. An option was identified as the ability to select for or against, strike through, add to, or limit.
Of the 51 total choices within the living will portions of the documents, an average of 13.4 choices were provided with a minimum of 0 (MA, MI, NY) and a maximum of 75 choices (VT). Twenty-three states provided <10 options, and 10 states provided >20 options. Advance directives from each state vary significantly in both the number and type of end-of-life options offered. The potential for choice overload combined with other previously investigated barriers may explain the low completion rates of advance directives.
Of interest and perplexing is the fact that when people are completing advance directives with an attorney, typically no explanation of their options is given to them. Patients do not consent for medical procedures without first receiving counseling, so why are documents that regard medical decision making, and potentially opting out of medical care, being completed without counseling?
This process can be improved, simplified, and lead to more “buy in” from the public. The simplest option is a national acceptance of the Physician Orders for Life-Sustaining Treatment (POLST), which is a solution that currently exists.
—Peter Averkiou, MD
Assistant Professor of Integrated Medical Science
Charles E. Schmidt College of Medicine, Boca Raton, Florida
paverkiou@health.fau.edu