JOURNAL OF PALLIATIVE MEDICINE

Volume 21, Number 7, 2018

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2018.0095

Development and Pilot Testing of a Motivational

Interview for Engagement in Advance Care Planning

Terri R. Fried, MD,1,2 Stephanie L. Leung, PhD,3

Laura A. Blakley, PhD,4,5 and Steven Martino, PhD5,6
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Dear Editor: approach is used to deliver ACP education in an MI-consistent

Motivational interviewing (MI), a person-centered coun-
seling approach in which the clinician helps individuals ex-
plore and resolve ambivalence about behavior change,1 has
been successfully employed to improve outcomes for be-
haviors including substance use, diet, and exercise.2 Theories
of behavior change have been shown to explain engagement
in advance care planning (ACP).3 MI may serve as a useful
approach to bridge the gap between intensive clinician-led
programs, and self-administered tools to promote ACP en-
gagement. We developed and pilot tested an MI intervention
for ACP.
The MI manual was written in an iterative process by an
interdisciplinary team with expertise in MI and ACP. MI
sessions were delivered by two health psychologists who
were trained in general MI through a two-day workshop and
received additional feedback during role-playing sessions.
Sessions were conducted by telephone, audio-recorded, and
reviewed using a modified version of the Independent Tape
Rater Scale (ITRS), a reliable and valid measure that yields
MI adherence and competence scores on 7-point Likert scales
from not at all/very poor to extensively/excellent for five
fundamental and five advanced MI strategies.4 The ITRS also
assessed motivation for participation in ACP at the beginning
and end of each session using a 7-point scale.
The MI intervention consists of four steps as follows: (1)
elicitation and clarification of patient’s understanding of and
current engagement in ACP, (2) building motivation for
ACP, (3) developing a change plan, and (4) summarizing the
overall discussion. ACP is discussed in terms of four be-
haviors as follows: (1) appointing a healthcare agent; (2)
communication about the patient’s values, with an exercise
examining attitudes toward quality versus quantity of life; (3)
completion of advance directives (ADs); and (4) ensuring
that ADs are in the medical record. The elicit-provide-elicit
manner. MI sessions were conducted with four male and two
female veterans ranging from 64 to 75 years (mean 68.3;
standard deviation [SD] 4.8) receiving treatment for post-
traumatic stress disorder (n = 1), major depressive disorder
with anxiety (n = 1), cancer (n = 2), and multiple chronic con-
ditions (n = 2). Ratings for MI adherence and competence
(Fig. 1) demonstrate that all sessions were delivered with at
least adequate proficiency for both fundamental and advanced
MI strategies. Panel C illustrates high levels of motivation for
ACP engagement at the beginning of the sessions that none-
theless increased further by the end. The sessions lasted a mean
(SD) of 34.9 (6.5) minutes, with a range of 26.7–46.0. Clin-
icians spent most time on clarifying values regarding quality
versus quantity of life and preparing a change plan.
MI can be delivered in relatively brief sessions, reaching if
not exceeding adequate thresholds of performance for both
fundamental and advanced MI skills. Although it can be easy
for the patient to become a passive recipient of information in
ACP education, the MI intervention elicits the patient’s ac-
tive participation in this process, in the context of helping the
patient to understand his or her motivations for engagement.
Additional work is necessary to develop methods for in-
volving surrogates and to examine clinical outcomes in larger
samples.
Acknowledgments
This study was supported by Merit Review Award Number
I01 HX HX002062 from the U.S. Department of Veterans
Affairs Health Services Research and Development Service
of the VA Office of Research and Development. The views
expressed in this article are those of the authors and do not
necessarily represent the views of the Department of Veter-
ans Affairs.

1
Clinicial Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut.
2
Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
3
Wyckoff Heights Medical Center, New York, New York.
4
Palliative Care Service, VA Connecticut Healthcare System, West Haven, Connecticut.
5
Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.
6
Psychology Service, VA Connecticut Healthcare System, West Haven, Connecticut.

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 898 LETTERS TO THE EDITOR
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FIG. 1. Panel (A) shows ratings for clinician fundamental MI adherence (black bars) and competence (gray bars). Panel (B)
shows ratings for clinician advanced MI adherence (black bars) and competence (gray bars). Adherence was rated 1 = not at all,
2 = a little, 3 = infrequently, 4 = somewhat, 5 = quite a bit, 6 = considerably, and 7 = extensively. Competence was rated 1 = very
poor, 2 = poor, 3 = acceptable, 4 = adequate, 5 = good, 6 = very good, and 7 = excellent. A rating of 4 or higher for both
adherence and competence represents adequate proficiency in the delivery of MI. Panel (C) shows ratings for patient
motivation at the beginning (black bars) and at the end (gray bars) of the MI session. Motivation was rated 1 = not at all,
2 = very weak, 3 = weak, 4 = adequate, 5 = strong, 6 = very strong, and 7 = extremely strong. MI, motivational interviewing.

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2. Lundahl BW, Kunz C, Brownell C, et al.: A meta-analysis of Address correspondence to:
motivational interviewing: Twenty-five years of empirical Terri R. Fried, MD
studies. Res Soc Work Pract 2010;20:137–160. Clinicial Epidemiology Research Center
3. Fried TR, Bullock K, Iannone L, et al.: Understanding ad- VA Connecticut Healthcare System
vance care planning as a process of health behavior change. 950 Campbell Avenue
J Am Geriatr Soc 2009;57:1547–1555. West Haven, CT 06516
4. Martino S, Ball SA, Nich C, et al.: Community pro-
gram therapist adherence and competence in motivational E-mail: terri.fried@va.gov