Association of Participation in an End-of-Life Conversation Game With Advance Care Planning Behavior and Perspectives Among African American Individuals

Abstract

IMPORTANCE Less than 25% of African American individuals have completed advance directives and are thus vulnerable to poor end-of-life care. Low-cost interventions are needed to increase engagement in advance care planning (ACP).OBJECTIVES To investigate whether an end-of-life conversation game motivates African American attendees to engage in ACP and to assess whether the game is well received and endorsed.EXPOSURES Attendance at an end-of-life conversation game (Hello) played in groups of 4 to 6 participants for 60 minutes. DESIGN, SETTING, AND PARTICIPANTS Prospective, mixed-methods cohort study conducted from 2018 to 2019 with a 3-to 11-month follow-up interview. Game events were held in 53 community venues across the US; 15 were purposively sampled for onsite research procedures. Of 428 attendees at purposively sampled sites, 386 (90%) consented to research procedures (6 attendees were removed from analysis for protocol deviation). Of 367 attendees who provided accurate contact information, 232 (63%) were contacted, and 220 were included in follow-up analyses. MAIN OUTCOMES AND MEASURESThe primary outcome was advance directive completion rates after the intervention. Secondary outcomes included rates of other ACP behaviors, ACP engagement, conversation satisfaction and realism, and participants' Net Promoter Score (a measure of endorsement). Follow-up telephone interviews explored the game experience and relevant ACP behaviors of attendees. RESULTS Of 380 individuals who participated (mean [SD] age, 62.2 [13.8] years; 304 were female [80%], and 348 were [92%] African American), none withdrew because of an adverse event. After the intervention, 91 of 220 attendees (41%) completed a new advance directive; 176 of 220 attendees (80%) discussed end-of-life wishes with loved ones, and 214 of 219 attendees (98%) completed at least 1 ACP behavior. There was a moderate increase in the self-efficacy domain on the ACP Engagement Survey (mean [SD] change from before to after the game, 0.54 [0.98]; P < .001).The mean (SD) conversation satisfaction score was 6.21 (0.93) (range, 1-7, with 7 being highest satisfaction), and the overall Net Promoter Score was 57.89 (range, −100 to 100, with 100 being highest endorsement). Interviews revealed 5 themes about the game: (1) it was a useful forum for ACP; (2) it provided new information and perspective; (3) it was emotionally beneficial; (4) it increased appreciation for ACP; and (5) it empowered and motivated participants to perform ACP.Mixed-methods integration showed convergence across data sets. (continued) Key Points Question Can a low-cost, easily scaled, end-of-life conversation game motivate underserved African American individuals to engage in advance care planning? Findings This national mixed-methods cohort study reaching 384 underserved African American individuals found that high rates of advance care planning behavior were associated with participation in game events at community venues. Meaning The end-of-life conversation game may be a useful tool for engaging und...

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature

“…Quantitative assessment of this game-based conversation intervention showed that the game was useful, provided new information and perspective, was emotionally beneficial, and empowered and motivated them to perform advance care planning. 269 Future research should encourage new approaches leading to more systematic implementation of advance care planning. Tools to increase integration of advance care planning decisions into care should be explored, especially those that are technologically based.…”

“… 25 Van Scoy and colleagues (2020) evaluated an hour video-based low-cost end-of-life conversation game to motivate non-Hispanic Blacks to complete advance care planning. 269 Game events were held in 53 community venues across the United States. During this intervention participants played a conversation game that prompted players to answer and discuss 20 questions about death, dying, and end-of-life care.…”

“…Quantitative assessment of this game-based conversation intervention showed that the game was useful, provided new information and perspective, was emotionally beneficial, and empowered and motivated them to perform advance care planning. 269 …”

Gamification for promoting advance care planning: A mixed-method systematic review and meta-analysis

“…29 Moreover, 16%–80% of participants reported signing an advance directive, updating the existing ones, or designating a healthcare proxy at follow-up in four studies. 28,31,32,34…”

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