Journal of General Internal Medicine

, Volume 22, Issue 7, pp 1007–1010

The Influence of Default Options on the Expression of End-of-Life Treatment Preferences in Advance Directives

  • Laura M. Kressel
  • Gretchen B. Chapman
  • Elaine Leventhal
Original Article

DOI: 10.1007/s11606-007-0204-6

Cite this article as:
Kressel, L.M., Chapman, G.B. & Leventhal, E. J GEN INTERN MED (2007) 22: 1007. doi:10.1007/s11606-007-0204-6



Advance directives promise to preserve patient autonomy, but research indicates that end-of-life preferences can be influenced by the way in which questions are posed.


To determine whether preferences expressed by geriatric patients on advance directives are influenced by the default response inherent in the question.


Mailed survey containing 1 of 3 versions of an advance directive.


General internal medicine outpatient medical practice.


Outpatients aged 65 or older (n = 106, response rate = 27%).


In the “withhold” version of the survey, participants indicated situations where they would want treatments withheld (i.e., the default preference was in favor of treatment). In the “provide” version, participants indicated situations where they would want treatment provided (i.e., the default preference was against treatment). In the forced-choice control version, participants made an explicit decision to withhold or provide treatment for each situation.

Main Outcome Measure

Participants’ treatment preferences.


Preferences differed by condition, F(2, 103) = 3.61, MSE = 0.09, η2 = .07, p = .03. Participants tended to express the default preference, and thus, were more likely to favor treatment in the “withhold” condition than in the “provide” condition. Preferences in the forced-choice control condition were intermediate.


The default inherent in a question can impact preferences for medical treatment. This default effect limits the utility of advance directives.


end-of-life preferencesdefaultsadvance directives

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Laura M. Kressel
    • 1
  • Gretchen B. Chapman
    • 2
  • Elaine Leventhal
    • 3
  1. 1.Department of PsychologyNew York UniversityNew YorkUSA
  2. 2.Psychology DepartmentRutgers UniversityPiscatawayUSA
  3. 3.Department of Internal Medicine, Robert Wood Johnson Medical SchoolUniversity of Medicine and Dentistry of New JerseyNew BrunswickUSA