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End-of-life preferences: a randomized trial of framing comfort care as refusal of treatment in the context of COVID-19

Hodges, Juliet, Stoyanova, Lily and Galizzi, Matteo M. (2023) End-of-life preferences: a randomized trial of framing comfort care as refusal of treatment in the context of COVID-19. Medical Decision Making, 43 (6). 631 - 641. ISSN 0272-989X

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Identification Number: 10.1177/0272989X231171139


Background: Rates of advance directive (AD) completion in the United Kingdom are lower than in the United States and other western European countries, which is especially concerning in light of the COVID-19 pandemic. UK residents typically complete an advance decision to refuse care (ADRT), whereas US versions of ADs present a more neutral choice between comfort-oriented or life-prolonging care. The purpose of this study is to test whether this framing affects decision making for end-of-life care and if this is affected by exposure to information about the COVID-19 pandemic. Methods: In an online experiment, 801 UK-based respondents were randomly allocated to document their preferences for end-of-life care in a 2 (US AD or UK ADRT) by 2 (presence or absence of COVID-19 prime) between-subjects factorial design. Results: Most (74.8%) of participants across all conditions chose comfort-oriented care. However, framing comfort care as a refusal of treatment made respondents significantly less likely to choose it (65.4% v. 84.1%, P < 0.001). This effect was exacerbated by priming participants to think about COVID-19: those completing an ADRT were significantly more likely to choose life-prolonging care when exposed to the COVID-19 prime (39.8% v. 29.6%, P = 0.032). Subgroup analyses revealed these effects differed by age, with older participants’ choices influenced more by COVID-19 while younger participants were more affected by the AD framing. Conclusions: The UK ADRT significantly reduced the proportion of participants choosing comfort-oriented care, an effect that was heightened in the presence of information about COVID-19. This suggests the current way end-of-life care wishes are documented in the United Kingdom could affect people’s choices in a way that does not align with their preferences, especially in the context of the COVID-19 pandemic.

Item Type: Article
Official URL:
Additional Information: © 2023 The Authors
Divisions: Psychological and Behavioural Science
Subjects: R Medicine > R Medicine (General)
B Philosophy. Psychology. Religion > BF Psychology
H Social Sciences > HV Social pathology. Social and public welfare. Criminology
R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Date Deposited: 04 Apr 2023 15:03
Last Modified: 02 Jun 2024 07:00

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