How defaults increased comfort-oriented end-of-life care by 16%

Intervention · Healthcare


When confronted by a decision that has a default option, unless we have strong preferences on the matter, we will probably take the path of least effort and go with the default. Strong preferences form when we are able to observe the outcome of a decision and adjust our preferences accordingly. This trial and error process may not matter for menial decisions, but what about significant once in a lifetime decisions? 

In this study, researchers wanted to find out how default options influence terminally ill patients’ end-of-life care decisions. Seriously ill patients were given one of three advance directives to complete. One had comfort-oriented care as the default, the other had life-extending care as the default, and the third did not have a default selected. The results show that seriously ill patients’ decisions on end-of-life interventions are heavily influenced by default options.


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Rating = 5/5 (significant results; good external validity; clearly explained research process)

Seriously ill patients prefer quality of life over life extension
Comfort-oriented care as the default 77% retained the default choice
Life-extending care as the default 57% retained the default choice
No default 61% selected comfort-oriented care

Key Concepts

Default: a pre-selected option that will be applied if a person does not actively make a choice. It is one of the most broadly used tools in the choice architecture toolbox.

Choice Architecture: presenting choices in a certain way to influence people’s decisions. 

Status-Quo Bias: our preference for keeping things as they are or maintaining a certain state. 

Advance directives: legal documents that allow a person to state their end-of-life care preferences before they become too ill to make their own healthcare decisions. 

The Problem

The norm to extend life

If the end-of-life care decision of a seriously ill patient is left up to healthcare professionals, the decision would likely be to extend the patient’s life as much as possible. However, patients and the general public agree that improving quality of life is more important than life extension.¹ This disparity is most problematic when a patient has reached a stage where they can no longer express their end-of-life care wishes. To avoid this, seriously ill patients are encouraged to fill in advance directives before they reach this point. However, the implicit bias towards life-extending care is still often evident in these documents through their format and wording.² This shapes patients’ decisions, potentially resulting in them receiving care that does not reflect their true wishes. 

Decisions, discussions, and defaults 

To grant a patient’s true end-of-life treatment wishes, the patient must first know their preferences. If the treatment options have not been carefully considered with the help of professionals and family, an instantaneous decision is made sans deep reflection or open discussion. With no strong prior preferences, patients are more vulnerable to the effect of defaults and choice orderings, with the potential for seriously ill patients to not receive the treatment they truly want. Time and resources are spent in vain, and loved ones may suffer over the responsibility of making a choice. 


The patients

The study subjects were 132 seriously ill patients above the age of 50. They were recruited from the Hospital of the University of Pennsylvania between May 2010 and January 2012. Eligible patients met with a research nurse who explained the study, potential benefits of advance directives and answered any questions the patients had. The patients were informed that they would be randomly assigned different advance directives, but that each had the same options available. They were advised to consult their family members and physicians before making a decision. The patients were also reassured they could change their decision at any point. 

Three different advance directives 

One of three advance directives were assigned to each patient. The advance directives had the same options but differed on whether they had defaults, and the default option selected. One-third of the patients received an advance directive with comfort-oriented care as the default. This option would focus on reducing pain instead of on interventions to extend life. Another-third received an advance directive with life-extending care as the default, where the end-of-life care treatments would focus on extending life. The last group received standard advance directives with no default selected leaving all patients to actively make a decision. 

Revealing the conditions

After the advance directives were returned, patients were debriefed by an investigator. The exact differences between the advance directives were revealed and the goals of the study were explained. Finally, the patient’s choices were read back to them and they were asked if they would like to adjust their choices. 

The MINDSPACE Framework

This study used an element from the MINDSPACE Framework. This framework sets out nine powerful elements that influence human behavior: messenger, incentives, norms, defaults, salience, priming, affect, commitments, and ego. This framework provides a checklist to better understand behavior change, improve attempts to influence behavior, and reassess policies that have been implemented to shape behavior. 

This study focused on the behavioral dimension of defaults. Default options, if used effectively, are surprisingly good at shaping decisions as they are often accepted by individuals even if it isn’t their true preference. This may be due to our tendency to resist change, follow norms, and maintain the current state of affairs, also known as the status quo bias

Results and Application

Quality of life over life extension

The defaults had a significant influence on the proportion of patients who chose comfort-oriented care. The study found that 77% of patients who received the advance directives with comfort-oriented care as the default stuck with this choice, while only 57% in the life-extension default stuck with their choice, and 61% selected comfort in the standard advance directive group.

Happy to be swayed

Patients were still satisfied with their choices after they were debriefed and informed about the defaults. This finding suggests that many seriously ill patients perhaps do not have strong preferences about end-of-life care. As a result, they are open to receiving guidance on making end-of-life care decisions.

Systemic defaults and patients’ real wishes

Standard advance directives do not have default options, so if patients don’t make a decision about their end-of-life care, clinicians or family members make the decision when the patient is no longer able to. Routine care is often geared towards extending a patients life, yet in contrast, most patients in the study opted for comfort-oriented care. So the present systemic default for life extension likely does not meet patients’ true preferences. The results of this study suggest that defaults in advance directives can be used to aid patients in making decisions that best meet their end-of-life care wishes. 

Climate & Energy Defaults can be used to guide people into making more environmentally friendly choices by having green alternatives as the default. For example, a green electricity tariff could be set as the default choice of energy or the option to pay for a carbon offset policy when booking a flight could be set as the default.3,3⁴
Insurance  When deciding on an insurance plan, biases in probability assessment and certain perceptions on risk can affect decisions about insurance plans. Defaults can be used to help people make smarter decisions regarding insurance plans by setting defaults based on less subjective perceptions and unbiased probability assessments. 
Public Policy Large effects can be seen when default options are used in organ donation systems and employer based pension schemes. An opt-out policy on becoming an organ donor increases the number of organ donors. Similarly, more employees sign up for pension plans when opting in was set as the default option.
Education Financial aid and loan application forms can be made with defaults that make it easier for students to obtain the finances they need for pursuing higher education.⁵ ⁶
Retail & Consumer Default options could be used in online stores to increase the demand for a specific version of a product, for example, to increase the purchase of organic goods.⁷


  • The study provides a simple solution to improving end-of-life care decisions. 
  • The patients are well informed and carefully guided throughout the process. 
  • Only patients with incurable diseases of the chest from one clinic were recruited.

Does the intervention demonstrably improve the lives of those affected by it?
Preferable end-of-life care improves the wellbeing of the patients and their loved ones.
Does the intervention respect the privacy (including the privacy of identity) of those it affects?
None of the participants were identified.
Does the intervention have a plan to monitor the safety, effectiveness, and validity of the intervention?
The different advance directives were randomly assigned. An Institutional Review Board approved the debriefing script.

Does the intervention abide by a reasonable degree of consent?
All patients signed an informed consent form after meeting with a research nurse who carefully explained the study to them
Does the intervention respect the ability of those it affects to make their own decisions?
Patients were encouraged to consult their physicians and family members before making a decision.
Does the intervention increase the number of choices available to those it affects?
Room for Improvement
The intervention did not increase the number of choices available to the patients. However, it provides a solution to help patients make decisions that meet their preferences.

Does the intervention acknowledge the perspectives, interests, and preferences of everyone it affects, including traditionally marginalized groups?
Insufficient Information
The intervention does not go into detail about the perspective of the doctors, nurses and family members, nor mentions marginalized groups.
Are the participants diverse?
Insufficient Information
There is no information on the diversity of the patients.
Does the intervention help ensure a just, equitable distribution of welfare?
The study ensured patients’ wishes are met, family is not burdened with care decisions, and resources are used efficiently. 

Related TDL Content

Can Defaults Save Lives? – The Power of Default Options on Life-Saving Decisions

The reason why you procrastinate ending that gym membership you never use might be the same reason why there is a huge discrepancy in organ donation rates between EU countries. This article discusses the role of default options in promoting organ donations.

A Nudge for Coverage: Last-Mile Problems for Health Insurance

How can data analytics be used to determine when defaults should be used as a nudge? When trying to change the behavior of 30 million people in the most effective and cost efficient way, combining data analytics and behavioral economics might be the way to go. 

Defaults improve savings

Retirement savings are essential for ensuring that one can have a good quality of life at an old age. Economic theory predicts that young individuals will save for retirement, but actual behavior seems to suggest otherwise. This article explains how defaults can help change savings behavior. 


  1. Baker, R., Mason, H., & McHugh, N. (2018, May 31). UK spends generously to extend the lives of people with terminal illnesses – against the public’s wishes. The Conversation.
  2. Halpern, S. D., Loewenstein, G., Volpp, K. G., Cooney, E., Vranas, K., Quill, C. M., McKenzie, M. S., Harhay, M. O., Gabler, N. B., Silva, T., Arnold, R., Angus, D. C., & Bryce, C. (2013). Default options in advance directives influence how patients set goals for end-of-life care. Health Affairs32(2), 408-417.
  3. Kaiser, M., Bernauer, M., Sunstein, C. R., & Reisch, L. A. (2020). The power of green defaults: The impact of regional variation of opt-out tariffs on green energy demand in Germany. SSRN Electronic Journal
  4. Araña, J. E., & León, C. J. (2012). Can defaults save the climate? Evidence from a Field experiment on carbon offsetting programs. Environmental and Resource Economics54(4), 613-626.
  5. Bettinger, E., Long, B. T., Oreopoulos, P., & Sanbonmatsu, L. (2009). The role of simplification and information in college decisions: Results from the H&R block FAFSA experiment.
  6. Cox, J., Kreisman, D., & Dynarski, S. (2018). Designed to fail: Effects of the default option and information complexity on student loan repayment.
  7. Anesbury, Z., Nenycz-Thiel, M., Dawes, J., & Kennedy, R. (2015). How do shoppers behave online? An observational study of online grocery shopping. Journal of Consumer Behaviour15(3), 261-270.
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