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Increasingly, ACP is viewed as a health behavior and applied to various behavioral change models including the Transtheoretical Model (TTM) of behavior change (Fried, Bullock, Iannone, & O'Leary, 2009; Fried et al., 2010; Pearlman, Cole, Patrick, Starks, & Cain, 1995). Initially identified by Prochaska and DiClemente (1983) and applied to smoking behavior, the model has since been applied to other behaviors. For example, in application to ACP, behavior change is viewed along a continuum ranging from: (a) precontemplation (e.g., not thinking about ACP); (b) contemplation (e.g., actively thinking about ACP); (c) preparation (e.g., commitment to engage in ACP); (d) action (e.g., undertaking ACP); and (e) maintenance (e.g., ongoing changes to ACP). Research has found that older adults are in different stages of readiness, as identified by different components of the model, as a result of many perceived benefits and barriers to planning, and that ACP does not represent the totality of one's planning for the EOL (Fried et al., 2009). Furthermore, past experiences with health care decision making for others represented a strong influence on their own perceptions of susceptibility and engagement in ACP. Additional research on the model suggests that a majority of older patients were found to be stuck in the precontemplation stage due to lack of communication with their providers (Fried et al., 2010). Recommendations from the study suggest tailoring discussions based on personal readiness to change and recommend that such discussions occur through non-medical settings, with other providers and paraprofessionals.

Personality Styles Associated With Decision Making

Distinct personality styles have been associated with ACP. In one grouping, personalities were identified in five subtypes, including: (a) Scramblers: forced to act in response to a serious health crisis; (b) Reluctant Consenters: pushed to make a change in care arrangements by relatives and professionals who notice a decline in health and functional independence; (c) Wake-up Caller: change care arrangements in response to a near crisis while health continues to deteriorate, thereby requiring greater levels of care; and (d) Advance Planners: research long-term care options and plan ahead while still healthy (Maloney, Finn, Bloom, & Andresen, 1996). Other research has identified (a) Avoiders: who try not to think about future care issues; (b) Thinkers: who are aware of future care needs, but make no plans;

(c) Planners: who think about and make concrete plans regarding their future care needs; and (d) Consenters: who adopt the plans devised by family members and others (Steele, Pinquart, & Sorenson, 2003). Accordingly, people differ in their willingness to plan ahead (Bailly & DePoy, 1995). Although research suggests that many people want to know what to expect in the course of their illness (Beisecker, 1988; Steinhauser et al., 2000) and services available to provide long-term care (Kane & Kane, 2001), others may be cognitively limited or unable to be involved in ACP.


This chapter has discussed considerations for ACP practice with older adults using a reconceptualization of traditional planning based solely on future health care decision making to a longer range, holistic view that incorporates multiple life domains. The importance of ACP with older people was discussed and trajectories of decline leading to the EOL were presented. Multiple care needs were addressed along with key domains for consideration in ACP practice with older adults. A behavioral change model (TTM) for ACP practice was presented along with research on personality styles associated with planning in advance for care.

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