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Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older AdultsA Nonrandomized Controlled Trial

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Can an advance care planning (ACP) video and communication intervention promote ACP for elderly patients during the ongoing COVID-19 pandemic?

Findings  This pre-post, open-cohort nonrandomized controlled trial compared ACP documentation during three 6-month periods: pre–COVID-19 (14 107 patients), COVID-19 wave 1 (12 806 patients), and an intervention period (15 106 patients). The ACP documentation rates were 17.9% in the pre–COVID-19 period, 12.5% in the COVID-19 wave 1 period, and 23.7% in the intervention period; ACP rates during the intervention period were highest compared with the 2 other periods.

Meaning  The use of an ACP video and communication intervention may promote ACP for elderly adults during the evolving COVID-19 pandemic.


Importance  COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models.

Objective  To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients.

Design, Setting, and Participants  The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre–COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included.

Main Outcomes and Measures  The primary outcome was ACP documentation.

Results  A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre–COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre–COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre–COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre–COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001).

Conclusions and Relevance  This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients.

Trial Registration  ClinicalTrials.gov Identifier: NCT04660422

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Article Information

Accepted for Publication: January 3, 2022.

Published: February 24, 2022. doi:10.1001/jamanetworkopen.2022.0354

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Volandes AE et al. JAMA Network Open.

Corresponding Author: Angelo E. Volandes, MD, MPH, Department of Medicine, Massachusetts General Hospital, 100 Cambridge St, 16th Floor, Boston, MA 02114 (avolandes@partners.org).

Author Contributions: Dr Volandes had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Tulsky and Lindvall are co–senior authors.

Concept and design: Volandes, Paasche-Orlow, Chang, LaVine, Carney, Martins-Welch, Davis, El-Jawahri, Fix, Garde, Fischer, Singh, Jacome, Tulsky, Lindvall.

Acquisition, analysis, or interpretation of data: Volandes, Zupanc, Lakin, Chang, Burns, LaVine, Carney, Emmert, Itty, Moseley, Gundersen, Yacoub, Schwartz, Gabry-Kalikow, Henault, Burgess, Goldman, Kwok, Singh, Alvarez Suarez, Gromova, Tulsky, Lindvall.

Drafting of the manuscript: Volandes, Zupanc, Chang, Carney, Itty, El-Jawahri, Yacoub, Schwartz, Burgess, Alvarez Suarez, Gromova, Lindvall.

Critical revision of the manuscript for important intellectual content: Volandes, Paasche-Orlow, Lakin, Burns, LaVine, Martins-Welch, Emmert, Moseley, Davis, El-Jawahri, Gundersen, Fix, Gabry-Kalikow, Garde, Fischer, Henault, Goldman, Kwok, Singh, Jacome, Tulsky, Lindvall.

Statistical analysis: Volandes, Chang, Emmert, Burgess, Singh.

Obtained funding: Volandes, Burns, Tulsky.

Administrative, technical, or material support: Volandes, Zupanc, Paasche-Orlow, Lakin, Burns, LaVine, Carney, Emmert, Itty, Moseley, Davis, El-Jawahri, Yacoub, Schwartz, Gabry-Kalikow, Fischer, Henault, Goldman, Kwok, Jacome, Tulsky, Lindvall.

Supervision: Volandes, Burns, Carney, Moseley, Davis, Garde, Tulsky, Lindvall.

Conflict of Interest Disclosures: Dr Volandes reported receiving personal fees from the Nous Foundation (dba ACP Decisions) outside the submitted work. Dr Lakin reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Chang reported receiving grants from the NIH during the conduct of the study. Dr Burns reported receiving grants from the NIH during the conduct of the study. Dr Davis reported receiving grants from the Nous Foundation (dba ACP Decisions) and serving as a former employee of Nous Foundation and currently as an unpaid volunteer outside the submitted work. Dr Fischer reported receiving personal fees from VitalTalk during the conduct of the study and outside the submitted work. Dr Tulsky reported receiving grants from the NIH during the conduct of the study. No other disclosures were reported.

Funding/Support: This work is supported within the NIH Health Care Systems Research Collaboratory by the NIH Common Fund through cooperative agreement UG3AG060626 from the National Institute on Aging. Supplemental funding for this work was provided by the NIH Common Fund under award 3UH3AG060626-03S1 from the Office of Strategic Coordination within the Office of the NIH Director. This work also received logistical and technical support from the NIH Collaboratory Coordinating Center through cooperative agreement U24AT009676.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views presented here are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Data Sharing Statement: See Supplement 3.

Additional Contributions: Marcel Salive, MD, MPH, National Institute on Aging, and Jeri Miller, PhD, MS, MSc, National Institute of Nursing Research, provided review and guidance of this trial. They were not compensated for their assistance.

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