Default options in advance directives strongly influenced patients’ end-of-life care choices, according to the authors of a recent study.1

“In a prior, smaller trial, we found that the ways in which advance directives are structured strongly influenced the choices made by seriously ill patients,” says Scott D. Halpern, MD, PhD, the study’s lead author. This affected whether patients wanted to maximize comfort or live as long as possible, and their preferences for life support interventions such as ventilators or feeding tubes.2

Some directives included preselected options for forgoing mechanical ventilation or other forms of life support. If so, patients were much less likely to choose to receive such interventions, even after the use of such defaults was explained to these patients.

In the larger subsequent study, researchers analyzed 492 seriously ill patients. “We sought to determine whether these impacts on patients’ choices in real advance directives would be replicated in a larger and more diverse cohort of seriously ill patients,” says Halpern, professor of medicine, epidemiology, medical ethics, and health policy at the University of Pennsylvania.

Halpern and colleagues also wanted to measure how the changes affected patient outcomes, such as the number of days survived outside the hospital. “Our two main findings were as expected,” Halpern reports.

Default options in advance directives again strongly influenced the choices patients made in completing these documents. Defaulting patients to receive comfort-oriented care did not reduce their number of hospital-free days. “However, we had anticipated that defaulting patients to more comfort-oriented care may produce certain other benefits,” Halpern explains.

The researchers expected to see improved quality of life, reductions in healthcare costs, or greater satisfaction with advance care planning. None of these outcomes were altered by the default options in advance directives. “This study confirms that contrary to popular belief, seriously ill patients’ choices about the types of care they wish to receive do not necessarily reflect deep-seated, well-ordered values,” Halpern reports.

Instead, decisions frequently are influenced by the ways in which choices are framed. “As such, clinicians and policymakers must be mindful of the language used in advance care planning conversations and documents,” Halpern stresses. For example, language can be used to encourage families to choose to forgo CPR in cases where the burdens outweigh the benefits.3

Overall, the findings point to the limitations of state-authorized advance directive forms, which focus narrowly on specific care choices. “We need to develop new approaches to advance care planning that more holistically incorporate patients’ goals and values,” Halpern suggests.


  1. Halpern SD, Small DS, Troxel AB, et al. Effect of default options in advance directives on hospital-free days and care choices among seriously ill patients: A randomized clinical trial. JAMA Netw Open 2020;3:e201742.
  2. Halpern SD, Loewenstein G, Volpp KG, et al. Default options in advance directives influence how patients set goals for end-of-life care. Health Aff (Millwood) 2013;32:408-417.
  3. Anesi GL, Halpern SD. Choice architecture in code status discussions with terminally ill patients and their families. Intensive Care Med 2016;424:1065-1067.