Readability of advance directive documentation in Canada: a cross-sectional study.

Background: In the Canadian context, health literacy has been shown to depend on place of birth, education level, socioeconomic status, language spoken and geographic location. This study seeks to determine whether currently available advance directive documentation in Canada is written in accordance with the average reading level of the population and to assess whether recommendations for health literacy are currently being met.

Methods: A cross-sectional study design was used. Patient-oriented English-language advance directive documents (brochures and/or forms) were obtained from the health agency websites of all Canadian provinces and territories and analyzed for readability using the Flesch-Kincaid Grade Level and Flesch Readability Ease scales.

Results: Advance directives in Canada are distinct from one another and surpass the recommended reading level by 4.5 ± 1.4 grade levels on average (95% confidence interval 8.7-10.3) with the hardest-to-read documents existing in Ontario, Quebec and Alberta.

Interpretation: These results demonstrate that the provincial and territorial governments issuing advance directive documentation have fallen short of their fiduciary responsibility to provide documents that facilitate health literacy. Addressing this shortcoming can result in increased patient engagement in advance directive completion while promoting patient autonomy.