Background  

Advance directives promise to preserve patient autonomy, but research indicates that end-of-life preferences can be influenced by the way in which questions are posed.

Objective  

To determine whether preferences expressed by geriatric patients on advance directives are influenced by the default response inherent in the question.

Design  

Mailed survey containing 1 of 3 versions of an advance directive.

Setting  

General internal medicine outpatient medical practice.

Participants  

Outpatients aged 65 or older (n = 106, response rate = 27%).

Interventions  

In the “withhold” version of the survey, participants indicated situations where they would want treatments withheld (i.e., the default preference was in favor of treatment). In the “provide” version, participants indicated situations where they would want treatment provided (i.e., the default preference was against treatment). In the forced-choice control version, participants made an explicit decision to withhold or provide treatment for each situation.

Main Outcome Measure  

Participants’ treatment preferences.

Results  

Preferences differed by condition, F(2, 103) = 3.61, MSE = 0.09, η ₂ = .07, p = .03. Participants tended to express the default preference, and thus, were more likely to favor treatment in the “withhold” condition than in the “provide” condition. Preferences in the forced-choice control condition were intermediate.

Conclusions  

The default inherent in a question can impact preferences for medical treatment. This default effect limits the utility of advance directives.