Promoting the end-of-life care decision-making process: Getting a foot-in-the-door

Individuals with life-threatening illness often avoid making end-of-life (EOL) care planning decisions. This study tested whether an incremental decision-making process known as the foot-in-the-door (FITD) effect led to more frequent completion of such decisions. A data set from a prospective controlled trial, which evaluated a care coordination program for patients with life-limiting illness, was analyzed to address this question. The data contained information for 573 participants, average age of 67.8 years, diagnosed with an advanced stage of cancer, congestive heart failure, chronic obstructive pulmonary disease, or end stage renal disease. Following the FITD process, the EOL care decision-making sequence was evaluated in four steps from (1) manipulating the presentation of advance directive decisions; to (2) formulation of advance directives; to (3) agreement to DNR/DNI physician orders; to (4) decision to select hospice care. Additionally, the relationship between FITD and Socioemotional Selectivity Theory (SST) variables were examined, as socioemotional selectivity has been shown to influence decision-making during life-limiting illness. SST related variables of perception of relationships (Social Provision Scale - Reliable Alliance Subscale) and emotional well-being (McGill Quality of Life Questionnaire - Psychological Symptoms Subscale) were evaluated. Consistent with the FITD process, each step in the decision-making sequence significantly predicted the next. Greater presentation of advance directive decisions led to increased advance directive formulation (p < .001). Advance directive formulation predicted increased agreement to DNR/DNI orders (p < .001). Finally, agreement to DNR/DNI orders predicted increased choice of hospice (p < .001). Also, perceptions of relationship reliability (p = .036) and emotional well-being (p = .040) varied significantly by the number of decisions participants made, indicating FITD processes may foster increased socioemotional adjustment with greater decision-making. Results support that FITD processes can be applied to promote greater EOL care decision-making. The study also finds support for SST variables at work within EOL care decision-making, as well as interaction between SST and FITD mechanisms. The results suggest that promoting completion of earlier and easier (less care restricting) planning decisions not only increases the likelihood of completing later decisions, but also fosters adjustments that support social and emotional well-being.