Counseling/Pastoral Care

Feasibility and Acceptability of a Brief Motivational Stage-Tailored Intervention to Advance Care Planning: A Pilot Study

American Journal of Hospice & Palliative Medicine® 1-9 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909115593736 ajhpm.sagepub.com

Eunjeong Ko, PhD1, Melinda Hohman, PhD1, Jaehoon Lee, PhD2, Ai-Nhat Ngo, MSW3, and Susan I. Woodruff, PhD1

Abstract Aim: This pilot study explored the feasibility and acceptability of a stage-tailored motivational interviewing intervention with education that focuses on changes in end-of-life (EOL) communication, completion of advance directives (ADs), and readiness for advance care planning (ACP). Methods: One group pretest–posttest design was implemented with 30 low-income older adults. Results: This pilot study showed its feasibility in enhancing ACP. Action for ACP—that is, identifying a proxy for decision making and documenting EOL treatment preference in an AD—increased significantly by 23.3% (n ¼ 7). The participants’ readiness for ACP, knowledge, self-efficacy, positive attitudes, and perceived importance of ACP increased significantly after the intervention. Conclusion: Health care professionals and service providers who interact with older adults should tailor ACP dialogues in accordance with individuals’ motivation. Keywords advance care planning, motivational interviewing, low income, older adults, feasibility, acceptability

Background and Introduction Advance care planning (ACP) is a process whereby individuals communicate their values and beliefs regarding end-of-life (EOL) care with their physician and family members and document their EOL treatment preference via advance directives (ADs).1 The ADs are legal documents in which individuals specify their preference for life-prolonging treatments (eg, a living will) and designate a surrogate decision maker (eg, health care proxy) in the event that they are unable to make their own decision. Despite its potential benefits to enhance autonomy in health care decision making, ACP has been underpracticed. A study by the California Health Care Foundation showed that only 23% of the public across all ages have completed an AD when compared to 47% of people aged 40 and older and 54% of people aged 60 and older, which is similar to figures reported in other national studies.2 End-of-life communication ranges from 41% to 62%, and most of EOL communication occurred with family rather than health care practitioners. Insufficient EOL communication leads to hesitation or delay in EOL decision making, which often leaves family members and physicians unaware of patients’ wishes and places families in a stressful situation when a crisis occurs.3-5 Interventions to promote one’s engagement in ACP have mainly focused on increasing his or her knowledge about AD via written material, visual aids, brief conversations with health care professionals, physician reminders,6 and counseling with health care professionals.7 Educational interventions have

yielded only minimal to moderate effects in increasing AD completion.8 More important, passive AD education alone did not produce significant impacts on AD completion when compared to interactive counseling.9,10 Previous studies11-13 showed that the level of readiness to engage in ACP varies among individuals, and such variation needs to be understood as an evolving process of behavior change. Planning EOL care is a complex yet fluid process that evolves through different phases. While the conventional educational approach primarily focuses on actual behaviors of completing AD, little is known about how the intervention makes individuals move forward along the stages of readiness to change.12,14 End-of-life decision making is thought to be a cognitive, emotional, and value-laden process that influences one’s motivation for behavior through different phases.12-17 Hence, there may be a need to reconceptualize ACP by shifting the focus from EOL decision making as a dichotomous outcome to a process of

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School of Social Work, San Diego State University, San Diego, CA, USA Institute for Measurement, Methodology, Analysis and Policy, Texas Tech University, Lubbock, TX, USA 3 UPAC Positive Solutions, San Diego, CA, USA 2

Corresponding Author: Eunjeong Ko, PhD, School of Social Work, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, USA. Email: [email protected]

2 eliciting individuals’ concerns, expectations, and goals of care.13,17,18 In line with such reconceptualization, tailoring EOL care planning to the individual’s readiness or stage of change instead of a ‘‘one size fits all’’ approach would be warranted.19 Motivational interviewing (MI) is a communication method designed to elicit and strengthen motivation for behavioral change.20 It has been found to be effective for various health care behaviors including alcohol misuse,21,22 smoking,23 and cancer screening.24,25 Recently, attention has been drawn on the applicability of MI in EOL/palliative care because of MI’s principles that value one’s ability to make his or her own decision fit well with the ACP values of autonomy and self-determination.26,27 Use of MI allows individuals to recognize their ambivalence for engaging in ACP and review their values and beliefs and achieve personal goals.27 Nevertheless, to our knowledge, there are limited studies exploring MI on the topic of ACP, particularly with low-income older adults. Low-income older adults are at risk of chronic physical and mental illness, limited functionality, and lack of social support. A recent study with low-income older adults found that only 19% of the sample (n ¼ 256) completed an AD,28 a figure that is lower than in the general public (27%). Thus, an effective intervention promoting ACP is imperative especially for this population. This pilot study assessed the feasibility and acceptability of a tailored MI counseling intervention combined with AD education on ACP. This study also examined preliminary outcomes of changes in (1) completion of ADs; (2) EOL communication; (3) progression in ACP stage of change; and (4) knowledge, attitudes, self-efficacy, and perceived importance of ACP after a tailored MI counseling combined with AD education.

Conceptual Model: Transtheoretical Model One conceptual model of health behavioral change, sometimes used in conjunction with MI, is the transtheoretical model (TTM).29 The TTM is considered as ‘‘compatible and complementary’’ with MI20 because it helps clinicians understand clients who are thinking about a change but not ready to move forward. MI was originally developed to motivate people in the direction of change.20 The TTM posits that individuals’ behavior changes through a process: precontemplation (no intention or plan to engage in changing behavior), contemplation (acknowledging the need for change and thinking about ways to change), preparation (preparing to take action), action (engaging in behavior change), and maintenance (continuing to engage in behavior change).29 Other concepts of TTM include processes of change which reflect affective, cognitive, and behavioral activities individuals engage in through the process30; decisional balance whereby people weigh the pros (benefits) and cons (barriers) in making a decision toward behavioral change; and self-efficacy which refers to one’s confidence to engage in behavior change.31 End-of-life studies using the TTM view engaging in ACP as a behavior change in a dynamic psychosocial process.32 Successful ACP occurs when individuals proceed from precontemplation

American Journal of Hospice & Palliative Medicine® or contemplation toward the action stage along with positive changes in their thoughts, feelings, and actions toward engaging in ACP.32,33 Passing through the stages toward the action stage, individuals gradually place more weight on the benefits rather than the barriers of ACP and gain self-efficacy.11,15

Methodology Needs Assessment As a preliminary step, older adults’ needs for ACP were assessed with 50 residents of a supportive housing facility and a senior center located in a low-income neighborhood. The needs assessment survey measured the participants’ preferred intervention methods and their level of perceived importance, confidence, and readiness to engage in ACP on a scale of 1 to 10, with a higher score indicating a greater level of perceived importance, confidence, and readiness. While the participants perceived EOL decision making as somewhat important (mean [M] ¼ 6.50, standard deviation [SD] ¼ 3.56), their confidence (M ¼ 5.50, SD ¼ 3.56) and readiness for ACP (M ¼ 4.68, SD ¼ 3.04) were low. Individual counseling was the most desired method of intervention delivery (n ¼ 33, 67.3%), followed by video education (n ¼ 6, 12.2%).

Study Design and Site Based on the needs assessment, a one-group pretest–posttest design was implemented to explore the feasibility, acceptability, and pilot outcome of a brief MI on ACP. The participants residing at a single supportive housing facility located in the Southwest United States were interviewed before and 1 month after a single-session intervention (see description subsequently). The supportive housing facility was a Department of Housing and Urban Development-related program that provided a permanent housing arrangement for low-income older adults, including homeless individuals and residents at a transitional housing facility.

Participants and Procedure Agency administrators and the San Diego State University Institutional Review Board (#1554095) approved the protocol for the current study and participant recruitment. Potential participants were recruited by a graduate assistant at the common areas of the facility or their rooms. Eligibility criteria for study participation included that the participants be of age 60 or older, cognitively able to participate, and had not already completed an AD. Cognitive competency was assessed by consulting the staff members who interact with the residents on a daily basis. The purpose of the study, the intervention procedure, and potential benefits and risks were explained during the consent procedure. A total of 70 older adults were recruited over a course of 5 months in 2014, and 22 were excluded for not meeting eligibility criteria (11 already completed an AD, 8 were cognitively incompetent to complete the study, 2 passed away,

Ko et al

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What do you already know about ACP?

Ask permission to discuss EOL care & provide AD information (Education)

How ready are you to engage in ACP?

Pre-contemplation “I have never thought about it”

Contemplation “I am thinking about participating in future EOL decision”

Planning “I have taken steps to (find more information about ACP)/talk about my EOL treatment with my doctor or family”

Stage-Matched MI Counseling

• Exploring values • Expressing empathy with concerns • Reflections of values and thoughts

• Exploring both sides of ambivalence (pros & cons) • Exploring motivation for ACP • Exploring discrepancies with values • Evoking motivation

• Summarizing values & emphasizing change talk • Establishing goals • Making specific plans to achieve goals

Figure 1. Stage-matched motivational interviewing (MI) intervention.

and 1 moved out of the facility prior to the initial interview). Among those 48 eligible older adults, 16 refused, yielding a response rate of 66.7%. The remaining 32 older adults completed a consent form and scheduled for the pretest. Two participants dropped out after the initial interview—one was evicted and the other was placed at an alternative facility for alcohol relapse. Thus, the final sample size with complete data was 30.

Intervention The single-session intervention consisted of stage-matched MI counseling and AD education. To enhance the consistency of the delivery of intervention, the first and second authors manualized the procedure. The AD education was provided in person using the California AD form34 which took about 10 to 15 minutes to cover. Education focused on (1) EOL treatment options and (2) the purpose and contents of an AD. Stagematched MI counseling was tailored to individuals’ readiness for change in ACP. At baseline, the participants’ motivation

toward ACP was assessed and MI communication was tailored in accordance with their stage of change (see Figure 1). The MI counseling focused on (1) exploring individuals’ values and beliefs regarding meaningful EOL, (2) eliciting individuals’ internal motivation toward behavioral change related to planning EOL care using reflective listening and other MI skills, and (3) assisting individuals to explore and resolve ambivalence in making EOL decisions. Reflective listening was used throughout the intervention that the participants’ values, perspectives, and preferences pertaining to plan EOL care were explored rather than being questioned or argued with, along with open-ended questions. Table 1 provides examples of these skills.

Training and Quality Control of Intervention The interviewer was a social work graduate research assistant who was trained in MI, having completed a graduate-level course that included 45 in-class hours. Her training included overview of ADs, MI counseling skills, and role-plays with

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Table 1. Examples of Dialogue Using MI Skills. Exploring the patient’s value and goals in end of life Clinician: What would be the quality of life look like for you? Patient: Talk to my family and friends, walk around . . . there are many things. Clinician: Being able to continue what you like to do is important for you. Patient: Oh yeah . . . otherwise what is the point to live? Clinician: So, let’s say, if something were to happen to you and you are not able to talk to your loved ones and enjoy daily activities, what would you want to happen at that point? Reflective listening: engaging with the patient Patient: I really haven’t thought about all of this stuff [end-of-life care planning]. Why should I bother making these kinds of plans? Clinician: You haven’t given this all much thought. Patient: No. This all seems like too much paperwork. I am not sure how I can say or write what I want now because I am not in that situation yet. Clinician: You are not certain about making a decision on medical treatments because it is difficult to know what is going to happen. Eliciting/Evoking the clients’ thoughts and ideas Clinician: Based on what you describe, you don’t want to depend on the machine to prolong your life. How will your loved ones know what your preferences are? Patient: It might be good for the family to know what I want but I haven’t actually talked about it yet. They will just know and will take care of it when the time comes. Clinician: You trust that your family will make the best decision for you. Patient: Absolutely. Clinician: On the one hand, you know that they will ensure your wishes and other the other hand, you are haven’t really discussed your wishes with them. Exploring both sides of ambivalence Patient: I just don’t think it is necessary for me to document my wishes. That’s thinking too far in advance. Clinician: You don’t think it is relevant and you don’t like planning ahead of time. Patient: I really haven’t thought about all of this stuff [end-of-life care planning]. Why should I bother making these kinds of plans? Clinician: It’s difficult to talk about this because you’ve never really thought about it before. Patient: Right. I’m perfectly healthy and haven’t faced any circumstances so I don’t know yet. I don’t think any of us do. Clinician: You are uncertain about making a particular decision on your future medical treatment because what will happen to you is unpredictable. If you were to document your wishes, what might be a benefit of doing this? Patient: Well, it might make it easier on my doctor or even my own kids. I don’t have much of a relationship with them but then they would know what to do. Clinician: It would take some of the burden off both your doctor and your children. What else might be a benefit? Abbreviation: MI, motivational interviewing.

different scenarios that varied by stage of change. Role-plays were audio-taped and evaluated by the first and second authors. For quality control, the first author, with the interviewees’ consent, observed 3 intervention sessions to ensure that the interventionist adhered to the study protocol.

Data Collection Procedure Data were collected at 2 time points: baseline and 1 month follow-up via face-to-face interviews by the same interventionist. Interviews were conducted at a private office of the study site. Both interviews were conducted with structured questionnaires and lasted approximately 20 to 25 minutes.

Measures In this study, 7 outcome variables were measured including EOL communication, AD completion, progression on stage of change, knowledge, self-efficacy, attitudes, and perceived importance toward ACP. Sociodemographic and healthrelated variables were also measured.

End-of-life communication was measured by asking the participants whether or not (yes/no) they had ever discussed what kinds of life-sustaining treatment they would want or not want if they become very ill and could not make such decisions themselves with significant others (family, friends, doctor, etc). The AD completion was assessed by recording whether the participants completed an AD, which corresponds to the action phase in stage of change. Stage of change was measured by asking the participants to indicate the stage of behavior reflecting their readiness: precontemplation (eg, have not thought about EOL care), contemplation (eg, considering making EOL decision), preparation (eg, taking a step to read more about ACP, seeking consultation about ACP), and action (eg, identifying potential health care proxies and documenting a proxy and EOL treatment preference in an AD). This measure was adopted from existing scales in the literature.12,15 Maintenance is the last stage in stage of change, but it was excluded in this study because unlike other behavioral issues such as diet, smoking, and drinking, once ACP is completed, the possibility of relapsing to an earlier stage is rare.

Ko et al Knowledge about ACP was measured by a modified AD knowledge scale35 which consisted of 7 items with binary responses (true/false). A total score could range from 0 to 7, with a higher score indicating a great level of knowledge. Attitudes toward ACP was measured by a decisional balance scale.33 This scale consists of 12 items assessing positive attitudes (pros) and negative attitudes (cons) about ACP. Response categories were 1 ¼ strongly disagree to 5 ¼ strongly agree. This scale has established high internal consistency for both pros (a ¼ .86) and cons (a ¼ .86). In this study, Cronbach a was .91 for each subscale. Self-efficacy was measured by a single item assessing how confident the participants felt about carrying out ACP. The response categories were 1 ¼ not confident at all to 10 ¼ very confident. Perceived importance was measured by a single item asking ‘‘How important is it for you to engage in advance care planning?’’ The response categories were 1 ¼ not at all important to 10 ¼ very important. Sociodemographic variables included age, gender, self-rated health (excellent, very good, good, fair, and poor), education, income, and hospitalization in the past year (yes/no).

Data Analysis Analysis focused on measuring pretest–posttest change in EOL communication, AD completion, stage of change, knowledge, attitudes, self-efficacy, and perceived importance. We compared means and frequency distributions of the study variables between preintervention (baseline) and postintervention (1 month). Given the dependency among observations (ie, repeated measurements of the same individuals), pairedsamples t tests were performed to compare means for the participants’ knowledge, attitudes, self-efficacy, and perceived importance. We also conducted McNemar test for categorical variables (EOL communication and stage of change) to examine homogeneity of their marginal distributions—that is, equality (lack of significant difference) between the preintervention marginal proportions versus the postintervention marginal proportions. Because the stage of change has more than 2 categories, a generalized version of the test was used for this variable. All analyses were conducted using SAS 9.3,36 and the SAS macro gMcNemar37 was used for the generalized McNemar test.

Results As shown in Table 2, the majority of the participants were male (60.0%) and half were white (50.0%). The average age was 69.1 years. More than half of the participants were separated or divorced, and 26.7% were never married. Ten percent had a high school diploma, 40.0% had some college or technical school education, and 30.0% had a college or graduate school degree; 90% had an annual income less than US$20,000. About 17% reported to be protestant and about two-thirds of the participants reported their health as excellent/very good or good, and one-third (33.3%) of them experienced a hospitalization

5 Table 2. Participant Characteristics.a Variables Age Male Ethnicity White Latino/Hispanic African American Other Marital status Separated/divorced Never married Widowed Married/living together Income Less than US$9,999 US$10,000-US$19,999 US$20,000-US$29,000 Education Some high school or less High school graduate Some college or technical school College graduate or postgraduate school Religion Protestant Catholic Other None Self-reported physical health Good/very good/excellent Fair Poor Self-reported emotional health Good/very good/excellent Fair Poor Hospitalization in ICU (Yes)

M (SD)

n (%)

69.1 (5.4) 18 (60.0%) 15 1 4 10

(50.0%) (3.3%) (13.3%) (33.3%)

16 8 4 2

(53.3%) (26.7%) (13.3%) (6.7%)

8 (26.7%) 18 (60.0%) 3 (10.0%) 6 3 12 9

(20.0%) (10.0%) (40.0%) (30.0%)

5 5 13 7

(16.7%) (16.7%) (43.3%) (23.3%)

19 (63.3%) 8 (26.7%) 3 (10.0%) 24 5 1 10

(80.0%) (16.7%) (3.3%) (33.3%)

Abbreviations: ICU, intensive care unit; M, mean; SD, standard deviation. a N ¼ 30.

in an intensive care unit (ICU) in the past year. The majority reported their emotional health to be excellent/very good or good. Only one-third (33.3%) of the participants had engaged in EOL discussions prior to the intervention, while almost half (46.7%) of them did so after the intervention. However, this difference was not statistically significant (w2[1] ¼ 1.00, P ¼ .32). Table 3 presents the frequencies and proportions of the participants in different stages of change at pre and postintervention. At preintervention, the majority of the participants were in the precontemplation stage (50.0%) followed by the contemplation (40.0%) and planning (10.0%) stages. Of those participants who moved to a next stage after the intervention, the majority were in the planning stage (46.7%) followed by the action stage (23.3%) in which they completed an AD. However, 8 (26.7%) remained in the precontemplation stage after the intervention. It needs to be noted that among the 7 participants who reported that they completed an AD at

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Table 3. Frequencies and Proportions in the Stages of Change Between Preintervention and Postintervention.a Postintervention Preintervention

Precontemplation (n ¼ 8)

Contemplation (n ¼ 1)

Planning (n ¼ 14)

Action (n ¼ 7)

7 1 0 0

0 1 0 0

5 6 3 0

3 4 0 0

Precontemplation (n ¼ 15) Contemplation (n ¼ 12) Planning (n ¼ 3) Action (n ¼ 0) a

N ¼ 30.

significant increase in perceived importance (t[29] ¼ 2.01, P ¼ .05). However, the participants’ negative attitudes (cons) toward ACP did not change significantly after the intervention (t[29] ¼ .11, P ¼ .91).

Table 4. Descriptive Statistics for AD Knowledge, Self-Efficacy, Attitudes, and Perceived Importance. Preintervention

Postintervention

Variable

n

M

SD

M

SD

P

AD knowledge Attitudes: pros Attitudes: cons Self-efficacy Perceived importance

30 30 30 30 30

3.27 24.00 13.97 5.93 6.47

2.85 5.90 6.25 3.33 3.60

5.47 25.93 14.07 7.67 7.63

1.74 5.72 6.91 3.03 3.08

.00 .03 .91 .01 .05

Abbreviations: AD, advance directive; M, mean; SD, standard deviation. a N ¼ 30.

postintervention, 6 left out the signature section. Although an AD without a witness signature is not ‘‘legally’’ valid, we considered such cases as in the ‘‘action stage’’ from the behavioral change standpoint because their behavior progressed further by identifying and documenting health care proxy (HCP) and their EOL treatment preference. The results of generalized McNemar test also indicated that the marginal distributions were not equal between preintervention and postintervention (w2[2] ¼ 11.27, P < .01). Given that no participant could be in the action stage at preintervention by design, the corresponding category was excluded from the analysis. Including this category (ie, zero count at preintervention) also produced the same results—that is, unequal marginal distributions (w2[2] ¼ 18.18, P < .01). The participants’ behaviors for ACP significantly changed after the intervention from precontemplation toward planning or beyond. Among those who did not complete an AD at postintervention (n ¼ 23), 6 (26.1%) reported that they identified a durable power of attorney, and all but 1 engaged in EOL discussion with the identified power of attorney. Among the 8 participants who were in the precontemplation stage at postintervention, 3 preferred to leave their EOL decision making up to the physicians, 2 were apathetic about ACP as they had no family,1 endorsed leaving the decision to God, and 1 felt uncomfortable thinking about EOL. Change in the participants’ knowledge, attitudes (pros and cons), self-efficacy, and perceived importance is shown in Table 4. The results of paired-samples t test indicated that participants showed significant increases in knowledge (t[29] ¼ 5.67, P < .001), positive attitudes (pros) toward ACP (t[29] ¼ 2.34, P < .05), self-efficacy (t[29] ¼ 2.62, P < .05), and

Acceptability and Feasibility Following the intervention, the interventionist collected log field notes documenting each participant’s opinions and perspectives toward the intervention. Content analysis was conducted to derive common themes from the log. Most participants (n ¼ 24, 80.0%) were receptive toward the intervention and considered it beneficial. For example, the participants stated: ‘‘I’m really glad I met you. I’ve wanted to do something like this.’’ ‘‘The important thing about this is that it makes me think about it. If you hadn’t brought this up, I wouldn’t have thought about it or even consider doing it.’’ As noted earlier, 32 (66.7%) of 48 participants agreed to participate in this pilot study by completing a consent form. Given that 75% or greater response rate is considered acceptable,38 the current response rate is somewhat low. However, it should be noted that supportive housing residents may be likely to refuse participating in a study because they are often transient and have a substance or psychiatric problems and a history of homelessness.39 Nevertheless, the dropout rate was low—only 2 participants (6.3%) dropped out from the study (due to eviction and rehab admission for alcohol relapse).

Discussion Our study explored the feasibility and acceptability of a stagematched brief MI with AD education in terms of changes in ACP. We also examined older adults’ knowledge, attitudes, self-efficacy, and perceived importance about ACP before and after the intervention. This study showed a promising result such that a brief MI with education can move individuals’ readiness toward ACP in a positive direction. Our findings showed a positive progression in stage of change such that the majority of participants moved to the next phases after the intervention. For example, half of the participants (n ¼ 15, 50.0%) were in the precontemplation stage before the intervention. While 7 of them remained in that stage, 5 moved to the planning stage, 3 to the action stage, and 1 to the precontemplation stage after the intervention. Similarly, among those in the contemplation phase prior to the intervention (n ¼ 12, 40.0%),

Ko et al 6 moved to the planning stage, and 4 to the action stage after the intervention. In addition, acceptability was demonstrated by the high follow-up rate and the positive comments about the intervention given at the follow up. While only 2 (6.3%) participants dropped out from the study (ie, low attrition rate), 16 participants refused to participate in the study (ie, low response rate). Although the reasons for refusal are unknown, it is likely that supportive housing residents have multiple issues such as physical and/or mental health problems, which often undermine their motivation for participating in a study. It is worthwhile to note that 23.3% (n ¼ 7) of the participants were in the action stage at postintervention, whereby they completed an AD. This figure may not be promising when compared to the previous finding that an interactive intervention could yield 23% to 71% of increase in AD completion.10 However, engaging in an action within a relatively short period (1 month) of the single-session intervention is somewhat encouraging. It needs to be noted that the majority of the participants in the action stage completed an AD ‘‘partially’’ with the incomplete witness’s signature section. They were not able to identify a witness and obtain the witness’s signature in such a short intervention period. Nevertheless, they made an action to plan EOL care by identifying a health care proxy and documenting EOL treatment preference. Hence, it is important to followup with clients to ensure that they fully complete an AD. While dialogues about EOL care over multiple times is suggested to be ideal to promote ACP,9 our results showed that a brief, single MI stage-tailored counseling approach may be effective in facilitating ACP. Tailoring messages to individuals’ readiness when compared to the traditional method of direct advice or persuasion may enhance client-centered communciation,40 which may in turn enhance willingness to make a decision. Noar and colleagues19 stated that individuals’ attitudes, skills, and procedures for behavioral change vary at different stages. Hence, tailoring messages might be necessary. Although some researchers argue that progression through the stages is necessary but not sufficient for behavioral change,41 having a personalized, tailored intervention may help individuals in their decision to move forward. Meanwhile, the changes in EOL communication were not statistically significant (33.3% vs 46.7%). This may be due to the short measurement schedule that may have left the participants insufficient time to initiate EOL discussions with their family and physicians. The majority of the participants lived alone, and some were estranged from family, with a history of homelessness. Among the participants, 8 (26.7%) reported to have no family contact. Another alternative explanation for the insignificant change in EOL communication is the small sample size. End-of-life discussion increased from 33.3% to 46.7% after the intervention. Absolute percentage change of 13.4% may be a meaningful finding but was not statistically significant at .05 a level. Post hoc power calculation indicated that an effect of this size would need 65 participants to be detected at .05 a level. Our findings showed that the intervention yielded significant changes in knowledge, positive attitudes, self-efficacy,

7 and perceived importance. After the intervention, the participants increased their knowledge and self-efficacy and greater levels of importance and positive attitudes toward ACP. It is noteworthy that this intervention did not yield any significant change in negative attitudes toward ACP. Negative attitudes increased among those in the precontemplation phase at postintervention. It may be that individuals, especially those in the precontemplation or contemplation stage, become more reluctant to planning EOL care after having in-depth communication about its negative aspects. This is consistent with current research in MI indicating that a decisional balance can decrease a commitment to change in those who are ambivalent.20,42 Nevertheless, it is important for individuals to have an opportunity to know and reflect on the pros and cons of ACP, a critical process in making an informed decision.43 Likewise, health care professionals who assess patients’ level of knowledge, self-efficacy, perceived importance, and attitudes toward ACP can better facilitate ACP decision making.

Limitations and Future Studies This was the first intervention study that explored the preliminary effectiveness of a stage-tailored MI intervention on ACP and explored its feasibility with a socially marginalized population. Despite a number of promising findings, there are several weaknesses that need to be addressed. This study included a relatively small sample of older adults recruited from only 1 site. In addition, the majority of the participants were male, contrary to most of other studies. Thus, the current study had limited statistical power and generalizability of its findings. It is uncertain to what extent MI components uniquely contributed to the observed changes when compared to education alone. In addition, other counseling methods or simple dialogue could have positively impacted on stages of changes for ACP. Hence, future studies using a randomized design that compare MI versus education interventions or other counseling methods can better detect the effectiveness of the MI intervention. Another weakness of this study is the relatively short interval between the intervention and the posttest (1 month). As a result, the participants who reported that they completed an AD could not make it legally effective without a witness’s signature. Endof-life studies implementing ACP interventions usually assess outcomes at least 4 to 6 months after the intervention7,44 and observe participants long enough to complete the AD process. In sum, future studies with a rigorous design and a longer time frame are warranted. Another limitation is that the same person conducted the intervention and interviews. This might introduce social desirability bias into the participants’ responses. It would be beneficial for future studies to separate interventionists and interviewers to enhance validity of study findings. This study was the first effort to tailor ACP communication in the context of individuals’ stage of change. Even with a number of limitations, this study suggests that a stage-based MI approach may be effective in enhancing ACP. Using an empathic counseling

8 method allows individuals to think through their options and concerns, based on their readiness to make a decision. Acknowledgment We thank all participants and staff members at Potiker Family Senior Residence, Serving Seniors at San Diego for their support.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

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