A pragmatic trial evaluates the effectiveness of a treatment or intervention in “real-world” clinical practice. Outcomes are typically assessed from available records. Eligibility in pragmatic trials are often broad, and don’t have the exclusions of efficacy studies, which examine treatment effects under highly controlled conditions in highly select populations.

Today we are delighted to welcome Jennifer Wolff, Sydney Dy, and Danny Scerpella, who conducted a pragmatic trial of advance care planning (ACP) in primary care practices; and Jasmine Santoyo-Olsson, who wrote an accompanying commentary in JAMA Internal Medicine.

We spend the last portion of the podcast discussing the surprising finding of the study. In the primary care practices that received the advance care planning intervention, rates of advance care planning were higher (about double). Shockingly, rates of potentially burdensome intervention (intubation, CPR, etc) were also higher in the advance care planning intervention group. What?!? Not a typo.

We spend some time unpacking and contextualizing the potential reasons for this surprising finding, including:

• Disconnect between relatively low rates of new advance directives (12% in intervention arm vs 7% control) and higher rates of potentially burdensome treatment among decedents (29% in intervention arm vs 21% control). Only 5% of intervention patients received the facilitator led component of the intervention (there were other components, facilitator-led was the most engaged component). Was there really a causal connection between the intervention, new advance directives, and higher rates of potentially burdensome interventions?

• Potential that care received, though potentially burdensome, was in fact aligned with goals, and might represent goal concordant care.

• Potential that documenting advance directives without a robust conversation about prognosis might have led to these findings. My goals will differ if I think I probably have 2 years to live vs 10 years.

• Comparison to a trial Yael Shenker discussed in our podcast on AAHPM/HPNA plenary abstracts (also used the Respecting Choices intervention, outcome differed).

• Implications for the larger discussion over the value of advance care planning, and additional research into advance care planning. As I say on the podcast, I’m sure Sean Morrison would be delighted to point to these findings as evidence that advance care planning doesn’t work, and in fact may be harmful.

And I got to sing in Spanish for the second time. I hope my pronunciation is better than my Urdu, or French!

-Alex Smith