Journal of General Internal Medicine

, Volume 22, Issue 7, pp 1007–1010 | Cite as

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



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, η 2 = .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 preferences defaults advance directives 



This research was supported by NSF award SES-03-25080 to the second author. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report. A preliminary report of these results appeared as a poster presentation at the November 2006 annual meeting of the Society for Judgment and Decision Making in Houston, TX.

Conflicts of Interest

None disclosed.


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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

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