Efforts to promote the completion of advance directives implicitly assume that completion rates of these documents, which help ensure care consistent with people's preferences in the event of incapacity, are undesirably low. However, data regarding completion of advance directives in the United States are inconsistent and of variable quality. We systematically reviewed studies published in the period 2011-16 to determine the proportion of US adults with a completed living will, health care power of attorney, or both. Among the 795,909 people in the 150 studies we analyzed, 36.7 percent had completed an advance directive, including 29.3 percent with living wills. These proportions were similar across the years reviewed. Similar proportions of patients with chronic illnesses (38.2 percent) and healthy adults (32.7 percent) had completed advance directives. The findings provide benchmarks for gauging future policies and practices designed to motivate completion of advance directives, particularly among those people most likely to benefit from having these documents on record.

Encouraging vaccination is a pressing policy problem. To assess whether text-based reminders can encourage pharmacy vaccination and what kinds of messages work best, we conducted a megastudy. We randomly assigned 689,693 Walmart pharmacy patients to receive one of 22 different text reminders using a variety of different behavioral science principles to nudge flu vaccination or to a business-as-usual control condition that received no messages. We found that the reminder texts that we tested increased pharmacy vaccination rates by an average of 2.0 percentage points, or 6.8%, over a 3-mo follow-up period. The most-effective messages reminded patients that a flu shot was waiting for them and delivered reminders on multiple days. The top-performing intervention included two texts delivered 3 d apart and communicated to patients that a vaccine was “waiting for you.” Neither experts nor lay people anticipated that this would be the best-performing treatment, underscoring the value of simultaneously testing many different nudges in a highly powered megastudy.

Patients engaging in shared decision making must weigh the likelihood of positive and negative outcomes and deal with uncertainty and negative emotions in the situations where desirable options might not be available. The use of “nudges,” or communication techniques that influence patients’ choices in a predictable direction, may assist patients in making complex decisions. However, nudging patients may be perceived as inappropriate influence on patients’ choices. We sought to determine whether key stakeholders, physicians, and laypersons without clinical training consider the use of nudges to be ethical and appropriate in medical decision making. Eighty-nine resident-physicians and 336 Mechanical-Turk workers (i.e., non-clinicians) evaluated two hypothetical preference-sensitive situations, in which a patient with advanced cancer chooses between chemotherapy and hospice care. We varied the following: (1) whether or not the patient’s decision was influenced by a mistaken judgment (i.e., decision-making bias) and (2) whether or not the physician used a nudge. Each participant reported the extent to which the communication was ethical, appropriate, and desirable. Both physicians and non-clinicians considered using nudges more positively than not using them, regardless of an initial decision-making bias in patients’ considerations. Decomposing this effect, we found that physicians viewed the nudge that endorsed hospice care more favorably than the nudge that endorsed chemotherapy, while non-clinicians viewed the nudge that endorsed chemotherapy more favorably than the nudge that endorsed hospice care. We discuss implications and propose exploring further physicians’ and patients’ differences in the perception of nudges; the differences may suggest limitations for using nudges in medical decisions.

Across 7 experiments (N = 3883), we demonstrate that communicators and targets make egocentric moral judgments of deception. Specifically, communicators focus more on the costs of deception to them-for example, the guilt they feel when they break a moral rule-whereas targets focus more on whether deception helps or harms them. As a result, communicators and targets make asymmetric judgments of prosocial lies of commission and omission: Communicators often believe that omitting information is more ethical than telling a prosocial lie, whereas targets often believe the opposite. We document these effects within the context of health care discussions, employee layoffs, and economic games, among both clinical populations (i.e., oncologists and cancer patients) and lay people. We identify moderators and downstream consequences of this asymmetry. We conclude by discussing psychological and practical implications for medicine, management, behavioral ethics, and human communication. (PsycINFO Database Record

BackgroundClinicians’ use of choice architecture, or how they present options, systematically influences the choices made by patients and their surrogate decision makers. However, clinicians may incompletely understand this influence.ObjectiveTo assess physicians’ abilities to predict how common choice frames influence people’s choices.MethodsWe conducted a prospective mixed-methods study using a scenario-based competency questionnaire and semistructured interviews. Participants were senior resident physicians from a large health system. Of 160 eligible participants, 93 (58.1%) completed the scenario-based questionnaire and 15 completed the semistructured interview. The primary outcome was choice architecture competency, defined as the number of correct answers on the eight-item scenario-based choice architecture competency questionnaire. We generated the scenarios based on existing decision science literature and validated them using an online sample of lay participants. We then assessed senior resident physicians’ choice architecture competency using the questionnaire. We interviewed a subset of participating physicians to explore how they approached the scenario-based questions and their views on choice architecture in clinical medicine and medical education.ResultsPhysicians’ mean correct score was 4.85 (95% CI 4.59 to 5.11) out of 8 scenario-based questions. Regression models identified no associations between choice architecture competency and measured physician characteristics. Physicians found choice architecture highly relevant to clinical practice. They viewed the intentional use of choice architecture as acceptable and ethical, but felt they lacked sufficient training in the principles to do so.ConclusionClinicians assume the role of choice architect whether they realise it or not. Our results suggest that the majority of physicians have inadequate choice architecture competency. The uninformed use of choice architecture by clinicians may influence patients and family members in ways clinicians may not anticipate nor intend.