Abstract
BackgroundA practical and ethical challenge in advance care planning research is controlling and intervening on human behavior. Additionally, observing dynamic changes in advance care planning (ACP) behavior proves difficult, though tracking changes over time is important for intervention development. Agent-based modeling (ABM) allows researchers to integrate complex behavioral data about advance care planning behaviors and thought processes into a controlled environment that is more easily alterable and observable. Literature to date has not addressed how best to motivate individuals, increase facilitators and reduce barriers associated with ACP. We aimed to build an ABM that applies the Transtheoretical Model of behavior change to ACP as a health behavior and accurately reflects: 1) the rates at which individuals complete the process, 2) how individuals respond to barriers, facilitators, and behavioral variables, and 3) the interactions between these variables.MethodsWe developed a dynamic ABM of the ACP decision making process based on the stages of change posited by the Transtheoretical Model. We integrated barriers, facilitators, and other behavioral variables that agents encounter as they move through the process.ResultsWe successfully incorporated ACP barriers, facilitators, and other behavioral variables into our ABM, forming a plausible representation of ACP behavior and decision-making. The resulting distributions across the stages of change replicated those found in the literature, with approximately half of participants in the action-maintenance stage in both the model and the literature.ConclusionsOur ABM is a useful method for representing dynamic social and experiential influences on the ACP decision making process. This model suggests structural interventions, e.g. increasing access to ACP materials in primary care clinics, in addition to improved methods of data collection for behavioral studies, e.g. incorporating longitudinal data to capture behavioral dynamics.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-2872-9) contains supplementary material, which is available to authorized users.
Highlights
A practical and ethical challenge in advance care planning research is controlling and intervening on human behavior
We developed an Agent-based modeling (ABM) depicting advance care planning (ACP) as a behavior change process using this Transtheoretical Model framework
We aimed to build an ABM the accurately reflects the rates at which individuals and the population complete the ACP process, barriers, facilitators, and behavioral variables
Summary
A practical and ethical challenge in advance care planning research is controlling and intervening on human behavior. Some research suggests that ACP, speaking with surrogates in advance, may aid in making more patient-centered decisions, and current best practices recommend incorporating surrogates and physicians in the ACP process by discussing patients’ end-of-life values and preferences with them prior to incapacitation [2, 4, 5]. Surrogates cite a variety of barriers to Ernecoff et al BMC Public Health (2016) 16:193 advance care planning, including the belief that an advance care plan is irrelevant due to perceived health, emotional barriers, relationship concerns, lack of information, and time constraints [7, 8] This suggests that overcoming the emotional and relational barriers may aid in integrating end-of-life values and preferences into future clinical care [2]. ACP rates among older and sicker populations remain relatively low, and understanding the mechanisms of advance care planning may help to target interventions to different stages in the behavior change process. [12]
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