An Assessment of Social Diffusion in the Respecting Choices Advance Care Planning Program

Abstract

This study examines the potential social diffusion effects of the Respecting Choices advance care planning program administered in La Crosse, Wisconsin, since 1991. The program produces educational materials for patients, trains facilitators to help patients prepare for end of life, and ensures that advance directives are connected to patients’ medical records. Using data from a survey of more than 5,000 White Wisconsin high school graduates in their mid-60s, we found that participants who were living in the La Crosse area were significantly less likely than their peers living elsewhere to have executed a living will or appointed a health care power of attorney. This pattern may reflect psychological reactance, where individuals reject a message or lesson when they perceive compliance as a threat to their autonomy. There was no evidence of social diffusion effects; participants who lived in the La Crosse region themselves or who had social network members residing in the area were no more likely than those with no known ties to the region to have engaged in advance care planning. Future studies should explore the processes through which individuals learn and share with others their knowledge of advance care planning.

Acknowledgments

This work was supported by the National Institute on Aging at the National Institute of Health (P01 AG21079, R01 AG09775, R01 AG13613), with additional support from the National Science Foundation (SES 9023082), the Spencer Foundation, the William Vilas Estate Trust, and the Graduate School of the University of Wisconsin.

Notes

Note. Means and standard deviations are presented for continuous measures; proportions are shown for categorical measures. One-way analyses of variance were used to assess mean differences; post-hoc comparisons were conducted to evaluate which subgroup differences were statistically significant. Significant subgroup differences are denoted as ab = residential versus social exposure; ac = residential versus no exposure; bc = social versus no exposure; DPAHC = durable power of attorney for health care.

†Computed only for currently married respondents whose spouses participated in the survey.

*p ≤ .05. **p ≤ .01. ***p ≤ .001.

Note. Participants in the reference category had no access to Respecting Choices. Regressions control for sociodemographic characteristics (gender, marital status, parental status, and educational attainment), physical health (self-rated health, recent hospital admission, perceived life expectancy, and presence of serious chronic illness), experiences with end-of-life issues (death of a parent or spouse), and values and attitudes (religious affiliation, death avoidance, and control over health decisions). Spousal congruence regressions include only currently married respondents whose spouses participated in the survey. DPAHC = durable power of attorney for health care.

*p ≤ .05. **p ≤ .01.