Health Policy and Systems

Developing a Parsimonious Model for Predicting

Completion of Advance Directives
Mary Judy Campbell, M. Jo Edwards, Karen S. Ward, Norman Weatherby

Purpose: To develop a theory-based model to assist nurses in promoting self-determination

for completion of an advance directive (AD).
Design and Methods: This descriptive study included data from a convenience sample of 118
community-dwelling older adults in Tennessee, USA. Multinomial logistic regression was
used to estimate the influence of 15 factors and covariates on completion of an AD.
Findings: The parsimonious model had three significant factors: receiving AD information;
attitude index; and health literacy score. Participants were highly likely to complete ADs
if they had positive attitudes toward ADs and had received information on ADs. As health
literacy increased, the likelihood that participants completed ADs was reduced. This model
explained 25% of the variation in AD completion. Chi-square fit for the parsimonious
model was highly significant.
Conclusions: Of 15 factors and covariates that could influence completion of an AD, only
receiving information about ADs, having positive attitudes toward ADs, and health literacy
significantly affected the likelihood of participants completing ADs. More study is needed
on this model and how nurses can assist patients with end-of-life decisions.

JOURNAL OF NURSING SCHOLARSHIP, 2007; 39:2, 165-171. 

C 2007 SIGMA THETA TAU INTERNATIONAL.

[Key words: advance directives, end-of-life care, palliative care]

* * *

N
urse researchers have contributed in numerous
ways toward understanding of factors that influ-
ence decision making about end-of-life care. A sim-
ple theoretical model for nurses to use in assisting patients
to document their wishes would be useful. An advance di-
rective (AD) document, which includes a living will and the
designation of a durable power of attorney for health care,
allows patients to make decisions in advance regarding med-
ical treatment at the end of life. However, ensuring that these
documents are initiated is an ongoing problem.
The Patient Self-Determination Act (PSDA; 1990) has
required that healthcare facilities receiving Medicare or
Medicaid funding provide every patient with information
about an AD and of their right to complete an AD. Ag-
gressive programs to implement the requirements of the law
have been carried out among different healthcare agencies,
and all 50 states have enacted legislation supporting ADs.
Despite these efforts, many recent studies still have indicated
only 20% or less of the general population have completed
ADs (DeLuca Havens, 2000; Hopp, 2000; Kemp, Emmons,
& Hayes, 2004; Mezey, Leitman, Mitty, Bottrell, & Ramsey,
2000, Salmond & David, 2005).
Self-determination has long been recognized as an ethi-
cal and legal principle in the US and is upheld through the
execution of an AD. When patients make decisions about
end-of-life care, they exercise personal autonomy. How-
ever, the research on exercising this right still shows vari-
ation from 4% to 69% of adults choosing to self-determine
(Bradley, Wetle, & Hortwitz, 1998; Decker & Reed, 2005;
Douglas & Brown, 2002; Gordon & Shade, 1999; Inman,
2002; Resnick & Andrews, 2002).
Aging Americans need help with end-of-life decisions
because 70% of those dying are over the age of 65 (Cen-
ters for Disease Control and Prevention, 2003). In addition,
80% of U.S. residents die in hospitals or long-term care facil-
ities where nurses should be engaging patients in discussions
on advanced care planning (Quill, 2000). A theory-based
model that indicates influencing factors on the behavior of
Mary Judy Campbell, RN, PhD, Xi Alpha, Associate Professor of Nursing;
M. Jo Edwards, EdD, Chairperson, Adams Chair of Excellence in Health
Care Services; Karen S. Ward, RN, PhD, Xi Alpha, Professor of Nurs-
ing, Professor and Associate Director Online Programs; Norman Weath-
erby, PhD, Professor of Health and Human Performance; all at Middle
Tennessee State University, Murfreesboro, TN. A Sigma Theta Tau Interna-
tional/Hospice and Palliative Care End of Life Nursing Care Research Grant
awarded in 2005 provided partial funding for conducting this research
study. Correspondence to Dr. Campbell, Middle Tennessee State Univer-
sity, School of Nursing, 1500 Greenland Drive, Box 81, Murfreesboro, TN
37132. E-mail: jcampbel@mtsu.edu
Accepted for publication December 27, 2006.

Journal of Nursing Scholarship Second Quarter 2007 165

Parsimonious Model
completing an AD can assist nurses in supporting a pa-
tient’s end-of-life decisions. Limited research has been re-
ported based on a theoretical framework to explain the
behavior of AD self-determination. The purpose of this
study is to provide a theory-based model for assisting
nurses in promoting self-determination for completion of an
AD.
Background
Investigators have studied a variety of influences on
the decision-making process on whether to execute or not
to execute an AD but only a few have identified behav-
ioral conceptual frameworks. Several researchers have used
the Health Belief Model to identify factors associated with
completion of an AD (Bradley et al., 1998; Hamel, Guse,
Hawranik, & Bond, 2002; Vandecreek & Frankowski,
1996). DeLuca Havens (2000) used the Stages of Change
Model to explore factors that could influence execution or
nonexecution of an AD as the patient progressed through the
stages of change. Westley and Briggs (2004) used the stages
of change model to identify ways to help nurses improve
communication about ADs. In addition, Moore and Sher-
man (1999) investigated community-dwelling older adults
using the theory of reasoned action to explain the personal
factors and family systems affecting the decision to complete
ADs.
Although these frameworks were used to explain the in-
fluences of individual factors on end-of-life decision making,
none of these studies included analysis of the relationship
of multiple factors on AD-completion rates. Social cognitive
theory indicates that psychosocial functioning entails triadic
reciprocal causation, in which behavior is influenced by a
triad of determinants (Bandura, 1986). The current study in-
cluded the triadic influences of selected personal, cognitive,
and environmental factors on decision making concerning
ADs among community-dwelling older adults.
Several studies have shown that personal factors influ-
enced patients’ decisions to execute ADs. Biological factors
such as older age and White ethnicity associated with higher
education increased the AD completion rate (Bradley et al.,
1998; Gordon & Shade, 1999; Hopp, 2000; Waters, 2000).
Gender has not been associated with completion of ADs. The
presence of a chronic illness has shown some association
with higher completion rates (Mansell, Dazis, Glantzy, &
Heeren, 1999; Mezey et al., 2000).
Attitudes among community-dwelling and hospitalized
patients have been studied as determinants affecting end-
of-life choices. Vandecreek and Frankowski (1996) investi-
gated an outpatient population and found significant as-
sociations between the amount of interest in completing
a living will and age, length of time that a diagnosis was
known, and family discussions about living wills. From in-
terviews of community-dwelling senior adults, Moore and
Sherman (1999) found overwhelmingly positive attitudes to-
ward ADs. Some of the reported beliefs about preparing an
166 Second Quarter 2007 Journal of Nursing Scholarship
AD document were that it prohibits someone from being
placed on artificial life support against specified wishes, re-
duces burdens to the family, and helps reduce costs of life-
prolonging care.
Three research teams used the same attitude question-
naire (Douglas & Brown, 2002; Nolan & Bruder, 1997;
Salmond & David, 2005). They all tested hospitalized par-
ticipants over the age of 18 and found moderately positive
attitudes toward ADs. Patients with more positive attitude
scores had higher AD completion rates, but no significant
relationships were found between the attitude score and par-
ticipants’ age, educational level, ethnicity, or marital status.
The influence of perceived control or self-regulatory ca-
pacity on completion of an AD has been studied. Mezey
et al. (2000) found the most frequent reasons given for want-
ing to execute an AD were personal choice, helping fam-
ily understand wishes about end-of-life care, and desiring
peace of mind. Completion of ADs increased when patients
discussed personal wishes with physicians (Mansell et al.,
1999) and patients also benefited from appointing a proxy
if patient, proxy, and physician were all educated about their
responsibilities (Goldblatt, 2001).
The presence of an illness or the death of a family mem-
ber can facilitate discussions with family members and pro-
fessionals (McDonald et al., 2003). Norton and Talerico
(2000) found that communication with patients and fam-
ilies about treatment choices, the possibility of death, and
providing comfort as central in making decisions near the
end of life. According to the SUPPORT study, nurses should
pay attention to the concepts of effective communication
and readiness when they engage in decision making with se-
riously ill clients (Murphy et al., 2001). However, barriers to
implementing decisions stated in an AD arise when the de-
cisions are not honored by the physician and the healthcare
agency (Meyers, Moore, McGrory, Sparr, & Ahern, 2004;
Murphy et al., 2001). Overall, the SUPPORT study showed
that discussions on ADs and better communication practices
did not necessarily lead to improved AD rates or improved
implementation of end-of-life wishes.
The influence of cognitive factors to help explain deci-
sions regarding end-of-life care has also been studied. Ad-
justing for other covariates, better knowledge of ADs was
significantly associated with being White, having at least a
college degree and having been a proxy for healthcare de-
cisions (Silveria, DiPiero, Gerrity, & Feudtner, 2000). Ott
and Hardie (1997) analyzed AD documents for readability
and noted a problem with reading comprehension: the av-
erage American is at the eighth-grade level but many of the
AD documents analyzed were written at a graduate school
reading level.
Researchers have found that patients were not equipped
to make decisions about end-of-life care based on their lim-
ited medical knowledge about end-of-life-choices (Brown,
Beck, Boles, & Barrett, 1999). For many people, access to
information is limited by their inability to understand in-
formation about important health matters. One study that
requires updating showed that about 90 million adults have

literacy scores that categorized them as reading below a high
school level and as functionally illiterate, and 44% of adults
over the age 65 scored at the lowest level (Kirsch, Jungeblut,
Jenkins, & Kolstad, 1993). Aging, low income, low educa-
tional attainment, and the presence of chronic illnesses have
all been associated with low health-literacy levels (Beers et
al., 2003; Schillinger et al., 2002). However, no studies were
found about health literacy as an influencing factor on de-
cisions to execute ADs.
Environmental influences on completing ADs were most
often associated with the housing setting of study partici-
pants, such as completion rates among institutionalized pa-
tients (Kemp et al., 2004; Mezey et al., 2000) or community-
dwelling clients (Decker & Reed, 2005; Molloy et al., 2000).
No studies were found on the influences of participating in
senior centers as an environmental determinant of comple-
tion of ADs.
Methods
This study was done to describe factors that influenced
completion of ADs. The convenience sample was drawn
from community-dwelling older adults attending six senior
centers in middle Tennessee, USA. Center newsletters and
posted flyers were used to encourage participation. Eligi-
bility for the sample included that participants were (a) 60
years of age or older, (b) alert and oriented to place and
person, and (c) able to speak and read English. Of the 212
older adults who consented to participate, 206 were able to
complete questionnaires.
Data were collected with a five-section questionnaire.
The first section was a short answer demographic survey.
The second section included the Advance Directive Atti-
tudes Survey (ADAS; Nolan & Bruder, 1997) and 16 ques-
tions to assess perceptions of ADs on a 4-point Likert scale.
The third section was the Short Test of Functional Health
Literacy in Adults (STOFHLA; Baker, Williams, Parker,
Gazmararian, & Nurss, 1999). The STOFHLA is a mea-
sure of health literacy, with a modified cloze method; par-
ticipants read passages in which every fifth to seventh word
has been deleted and health literacy is scored from inade-
quate to adequate. The fourth section, the Generalized Self-
Efficacy Scale (GSES; Schwarzer & Jerusalem, 1995), in-
dicates whether personal beliefs and resulting actions are
responsible for successful behavioral outcomes. Finally, the
Multidimensional Health Locus of Control (MHLC), Part
A, (Wallston, Wallston, & DeVillis, 1978) is a measure of
internal locus of control.
Because of the potential for missing data, a sample size
of about 115 participants was needed to achieve 80% power
with an alpha level of .05 for the logistic regression. In this
study, model development was based on data from 118 com-
pleted surveys to determine which factors influenced the
likelihood of completing ADs. Determination of the par-
simonious logistic regression model was based on compar-
isons of the chi-square model values. A p value of .05 indi-
cated statistical significance.
Parsimonious Model
Multinomial logistic regression analysis was used to esti-
mate the association of the specified factors and completion
of ADs. Two-way interaction terms were constructed from
combinations of the main effects, and these interaction mod-
els were tested. Because of relatively few participants, sets
of interaction terms were tested along with the main effects
instead of all interactions being tested at one time. A set
of interaction terms was deleted if it did not significantly
change the chi-square model. Insignificant interactions were
deleted, and main effects that were not significant or part
of significant interaction terms were deleted. The resulting
parsimonious model best explained the variation in the com-
pletion of ADs.
Findings
Demographic characteristics of the 206 participants in-
cluded: age range of 64 to 95 years (M = 73.4, SD = 7.47);
81% women and 19% men; 86% White, non-Hispanic,
11% Black, and 1% Asian, Hispanic, or American Indian.
The lowest level of education reported was sixth grade (1%)
and the highest level of education was 21 years or doctoral
degree (1%). Forty-two percent had completed high school
and 21.2% completed at least some college.
According to the completed data, 47.8% of the partic-
ipants reported that they had not received any information
on ADs and 46.6% said they had not been given any infor-
mation at hospitals or other agencies. Half reported having
ADs. When asked if they had a living will, 59.8% reported
Yes and 40.2% reported No. To the question about having
a healthcare power of attorney, 56.5% responded Yes and
43.5% No. When the three factors associated with comple-
tion of an AD were collapsed into one variable, the percent-
age who had completed ADs increased to 63.9% and the
percentage not having ADs was 36.1%.
The first index analyzed from the questionnaire was the
16-item ADAS. The scores ranged from 1 (strongly agree)
to 4 (strongly disagree). The mean for the ADAS was 3.24
(SD = .38). Internal validity for the ADAS survey was ac-
ceptable with a Cronbach’s alpha =.80. The relatively high
mean indicated that, on average, participants’ scores were
more positive than negative.
The second specialized index, the STOFHLA, was an-
alyzed as the number of correct items of 36 possible items.
The score per item was from 1 (correct) or 0 (incorrect).
The mean for STOFHLA was 29.10 (SD = 8.18). Internal
validity for the STOFHLA index was high with a Cronbach’s
alpha =.951. The mean score indicated more adequate than
inadequate health literacy.
A strong sense of self-efficacy or control was reported
in the participants’ GSES index with a mean of 3.13 of a
possible 4. Internal validity for the GSES survey was high
with a Cronbach’s alpha =.92. The six-item MHLC section
was based on a 6-point scale, from 1 (strongly disagree) to 6
(strongly agree). The mean for internal locus of control was
4.44 (SD = 1.06). Internal validity for the MHLC inventory
Journal of Nursing Scholarship Second Quarter 2007 167
Parsimonious Model

was high with a Cronbach’s alpha =.88. The results of this
analysis indicated a healthier internal locus of control among
those responding (n = 179). Only 8% of the participants
scored below 3 on this set of questions.
Data from the questionnaires were used to construct
15 independent variables for the logistic regression anal-
ysis. Multinomial logistic regression analysis was done
to develop a model based on the 15 possible predictors
for completion of ADs. Bandura’s triad of determinants
was represented in the analysis. The Table shows the
Main Effects Model (Step 1) and the Parsimonious Model
(Step 2).
Chi-square for the main effect model fit was 34.46
(df = 17, –2 Log Likelihood = 113.84, and p < .007). In this
model, the Nagelkerke R2 was .354, indicating that about
35% of the likelihood of older adults completing an AD was
explained by this model. Of the 15 main effects that were
analyzed in the initial model, only one variable, the attitude
index (ADAS), was significant at p = .004.
Interaction models were also analyzed. Each set of
two-way interaction terms was entered into the model-
development process in logistic regression. No significant
improvement in the chi-square model was found with
any of the interaction models, and all of the interaction
terms were dropped. Interactions of the factors and co-
variates did not significantly influence the completion of
ADs.
The main effect model was then reduced until the best-fit
model or parsimonious model was found (see Table). Chi-
square for the model fit was reduced to 22.84 (df = 3, –2
Log Likelihood = 125.41, and p < .001). The three main
effects analyzed in the parsimonious model were (a) atti-
tudes toward ADs, (b) health literacy levels, and (c) having
received information on ADs. These three remaining fac-
tors in the reduced model were all significant. Receiving AD
information (p = .013) and the attitude index using ADAS
(p = .008) increased the likelihood of the completion of ADs.
The health literacy score on STOFHLA was significant (p =
.002). The negative logistic regression coefficient (β = –0.20,
OR = 0.82) indicated that the more health literate an older
adult was, the less likely that he or she would complete ADs.
The likelihood was low for older adults to complete ADs if
they had negative attitudes toward ADs or had not received
information about ADs. The likelihood was high for older

Table. Summary of Logistic Regression Analysis on Predicting Completion of Advance Directives (N = 118)

Odds Wald
Variable β SE ratio statistic p

Step 1: Main effects model

Main effects
Constant –11.32 5.51 4.22
Sex
Female –0.05 0.64 0.95 0.01 .934
Male Reference .
Marital status
Widowed, divorced, single 0.70 1.04 2.04 0.44 504
Married or cohabitating Reference
Race
Black or other 1.10 0.95 3.00 1.33 .249
White Reference
Received AD information 0.90 0.65 2.46 1.91 .167
Given information at agencies 0.40 0.62 1.50 0.42 .518
Who makes decisions for you
Children –0.97 1.14 0.38 0.73 .394
Other and physician –1.26 1.30 0.28 0.95 .329
Spouse Reference
Health problems
Arthritis –0.25 0.85 0.78 0.09 .768
Other 0.21 0.69 1.23 0.09 .763
Heart disease Reference
Attend senior center 0.06 0.06 1.06 0.76 .384
Days of participation at senior center 0.20 0.18 1.22 1.19 .275
GSE index 0.34 0.58 1.41 0.35 .555
LOC index 0.28 0.30 1.32 0.88 .349
Attitude index 2.41 0.83 11.10 8.37 .004
Health literacy score –0.13 0.08 0.88 2.83 .093

168 Second Quarter 2007 Journal of Nursing Scholarship


adults not to have completed ADs if their scores indicated an
adequate level of health literacy. The Nagelkerke R2 value
for the parsimonious model was .247.
This model showed that 25% of older adult’s comple-
tion of ADs was explained by the parsimonious model. Of
15 possible factors that could influence completing ADs,
only 3 factors explained significant variance in the rate of
completing ADs in this sample.
Discussion
The parsimonious model showed that determinants
from both cognitive and affective factors influenced desired
behavior. Biological factors and the environmental factor
of participating in the senior center were not significant.
The environmental factor of community-dwelling partici-
pants was controlled by the study design. The parsimonious
model did not adequately explain the extent to which these
participants complete ADs. Although this study was limited,
findings can alert nurses working with older adults about
possible factors that influence completion of ADs.
Overall, the self-determination behavior of completing
ADs was higher than in some studies reported in the liter-
ature but was similar to findings in other research. Inman
(2002) studied about 50 community-based adults over the
age of 50 and had a 49% completion rate. A similar sample
reported by Decker and Reed (2005) had a completion rate
for living wills of over 69%. This study showed a similarly
high completion rate of nearly 65%.
The biological factors of age, sex, race, and health prob-
lems were all considered in the initial main effects model
(Step 1). Although these variables did not remain in the par-
simonious model (Step 2), the influence of biological fac-
tors on completing ADs has been shown in previous re-
search Bradley et al. (1998) found that the older the adult,
the higher the rate of completing an AD. Decker and Reed
(2005) also found a significant relationship between older,
White, female highly educated participants and higher rates
for executing living wills. The respondents in this study were
mainly well-educated, White women over the age of 65.
Some of the cognitive factors did have a significant influ-
ence on completion of ADs. Educational levels and knowl-
edge have previously been associated with completion of
ADs (Gordon & Shade, 1999). Educational level was not
a significant factor in the main effects model and did not
remain in the parsimonious model in this study. The mean
number of years of education in this study was over 12 years.
This educational level was higher than in some past studies
that showed low educational levels significantly associated
with low rates of completion of ADs. Higher educational
levels and higher completion rates were both found in this
study.
The knowledge associated with having received infor-
mation about ADs was significant in the parsimonious
model. Douglas and Brown (2002) found that 77% of their
sample had received information on ADs and the comple-
Parsimonious Model
tion rate was 43%. However, not all studies have shown
significant associations between knowledge and increasing
completion rates of an AD. Brown, Beck, Boles, & Barrett
(1999) found the intentional use of educational programs
to increase completion rates resulted in small increases in
the completion of ADs. The influence of knowledge and ac-
cess to information on AD completion rates requires further
study.
Health literacy had an unexpected and significant neg-
ative influence on completion rates for ADs in this study’s
sample, a finding difficult to understand. Participants with
higher levels of health literacy were less likely to have com-
pleted ADs than were those with relatively low health liter-
acy. One explanation could be related to the entire sample’s
overall higher-than-expected level of health literacy. With
over 80% of this sample at an adequate level of health lit-
eracy, variation in literacy levels among participants was
limited.
The unexpected direction of association between higher
health literacy and lower completion of ADs might also be
explained by the high percentage of those sampled, almost
90%, who had discussed their wishes about their end-of-life
care with family, physicians, or lawyers. This very health-
literate sample might have believed that discussion of wishes
with those who could act as surrogates was adequate with-
out the need of written documentation. Goldblatt (2001)
emphasized that an AD offers an advantage over surrogate
decision-makers, but reported that many people have re-
garded the surrogate as a default mode for completing writ-
ten instructions. Also, the idea has been proposed that fam-
ily support is an important factor in whether written ADs
are needed to make sure personal wishes are implemented
(Hopp, 2000). This highly health literate sample might have
believed that, if their wishes were known and they had strong
family support systems, then written instruction were not
necessary.
Although the completion of ADs has been shown to have
many advantages, the quality of the instruments and mech-
anisms used to assist with completing ADs can be improved.
Some studies (Brown et al., 1999; the SUPPORT trial, 2001)
indicated problems with the instruments and procedures for
documenting end-of-life care. Those older adults with higher
levels of health literacy might have recognized some of the
problems with the current mechanisms related to end-of-life
decision making and have chosen not to participate if de-
cisions might not be honored. More health-literate people
might feel that having family support for their decisions is
more important than is documenting decisions for health
professionals whom they might not know or trust. The im-
portance of health literacy levels on community-dwelling
older adults’ decision making about end-of-life care should
be further explored to better understand the influence of
literacy levels on completing ADs.
Finally, attitudes toward ADs were a significant factor
on AD completion. The high score in this study (50.15, SD =
7.08, range 18 to 64) indicate overall positive attitudes to-
ward ADs. Similarly high scores have been found in earlier
Journal of Nursing Scholarship Second Quarter 2007 169
Parsimonious Model
studies with a version of the same index. In the initial study
by Nolan and Bruder (1997), the mean was 50.38 (SD =
5.58, range = 17 to 68). Douglas and Brown (2002), using
an adapted version, had a mean score of 66.9 (SD = 6.3,
range = 22 to 88), and Salmond and David (2005), us-
ing the same adapted version of the ADAS, found a mean
of 58.78 (SD = 5.06). The mean in this study was simi-
lar to the means in all three studies even though all par-
ticipants in this study were over the age of 60. Overall,
the findings from the ADAS scores showed a strong belief
in personal autonomy; 95% of those surveyed agreed that
they would be given choices about treatment received at the
end of life.
One of the limitations of this study was the sample. The
self-selection method used to elicit an adequate sample size
might have biased the findings, and the length of the ques-
tionnaire might have influenced the number of completed
surveys. Finally, the overall sample size was small for draw-
ing generalizations.
More study is recommended on the use of Bandura’s
Social cognitive theory to explain the relationship of pos-
sible triadic determinants on end-of-life decisions. The par-
simonious model showed only three factors that were sig-
nificantly associated with completion of ADs. Interaction
of multiple determinants was not significant, indicating that
repeated studies with larger more diverse populations are
needed to further determine the relationship of interacting
factors on end-of-life decision making. In addition, the en-
vironmental influence of associating with other older adults
at community centers has not been thoroughly studied and
needs more exploration.
Conclusions
Study results indicated that completion of ADs in this
sample was influenced by information, attitudes, and health
literacy. For successful use of ADs, family members, nurses,
and physicians must communicate with those about whom
they are concerned and help them believe that what they
are sharing is valuable and that their wishes will be hon-
ored. The model developed through this study is a begin-
ning point in assisting patients and healthcare personnel in
self-determination for advance care planning.
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