Decisional capacity and information comprehension in the execution of advance directives in an aged population

Kathy Ann Hollingsworth


With the passage of the PSDA (1991) written advance directives are becoming the standard modality of expressing one's end of life treatment decisions. These documents, however, are being written on a level which surpasses the average person's reading and comprehension abilities. As the PSDA does not require explanation of the information, and with no evidence suggesting that health care facilities are extending beyond the basic requirements, it becomes imperative to identify those patients who will understand the documents without explanation. It is the supposition of the author that, without ensuring comprehension, we are not ensuring decisional capacity, a factor that is a necessity to the completion and enactment of advance directives. The purpose of this study was to compare the Hopkins Competency Assessment Test (HCAT; Janofsky et al., 1992) and the Flynt-Cooter Reading Inventory for the Classroom (RIC; Flynt & Cooter, 1998) in order to assess predictiveness of comprehension of written advance directive documents. It was hypothesized that due to the quantitative readability assessment utilized in the RIC along with the fact that it was presented in the same modality as the advance directive (written), it would account for a significant amount of variance in the scores on comprehension of advance directives. As the HCAT was presented orally, it was hypothesized that it would not account for a significant amount of variance in the scores on comprehension of advance directives, as it is measuring aural comprehension. Results of the regression indicated that neither the RIC nor the HCAT accounted for a significant amount of variance in the follow-up questionnaire that measured comprehension of advance directives. Thus, neither were shown to be accurate predictors of comprehension of advance directives. It was also hypothesized that comprehension of advance directives would be low. However, participants scored highly on the follow-up measure, thus not supporting this hypothesis. Results of this study further indicate that geriatric participants scored highly on follow-up measures, indicating high comprehension of advance directives. However, given statistical limitations of the study (e.g., floor erect of RIC; ceiling effect in comprehension measure; suppression), generalizability of these findings to the population at large is limited.