The Effects of Sociodemographic and Psychosocial Factors on Advance Care Planning

Background and Purpose: Advance care planning is an opportunity for people to express how they want to spend the final stage of their lives by directing what type of medical treatment they wish or do not wish to receive.  People can exercise their autonomy by completing such planning.  Autonomy is one of the fundamental ethical principles in medicine in the United States.  Many older adults in the U.S., however, do not have such a plan or even discuss the topic with anyone.  Many studies have examined persons’ sociodemographics in relation to their completion of advance care planning.  Few studies, however, have investigated psychosocial factors or examined this relationship with a nationally representative sample.  In order to understand the circumstances in which advance care planning is enacted, this study investigated sociodemographic and psychosocial factors that enhance or impede the completion of advance care planning.  The study used data from the Health and Retirement Study (HRS), a nationally representative sample of Americans over 50. 

Methods: The analytic subsample included HRS participants who died between 2006 and 2010 (N = 2,760).  Three separate logistic regression analyses were executed for each outcome: whether they had an informal discussion, living will, or durable power of attorney for health care (DPAHC).  Sociodemographic variables included participants’ age at death, gender, race, education, income, and marital status.  Psychosocial variables were drawn from their final personal interviews when they were still alive, including one’s experience of losing a spouse, sense of control (constraints and mastery), and religiosity.  Illness-related variables were controlled for, such as types of illness that led to participant death and the duration of the terminal illness.  

Results: A little over 60% of the deceased had an informal discussion (61%) and a DPAHC (64%).  Slightly less than half of the deceased documented a living will (49%).  The analyses revealed that the deceased who were older, female, White, had higher levels of education, or widowed were significantly more likely to have completed advance care planning.  A higher level of sense of mastery was only associated with increased odds of having documented a living will. 

Conclusion and Implications: The findings may suggest that a right to direct one’s medical treatment is undermined among certain subpopulations.  As previous research suggests, if distrust of the medical system and culturally rooted perspectives or attitudes are the reasons for the lower completion rates among racial minority groups, then delivering accurate information about advance care planning, including its purposes and benefits, to this population is important. In addition, for those with limited education, improving accessibility and availability of advance care planning is critical.  The significant effects of the perceived mastery level on a living will may reflect that documenting this will requires a higher level of motivation to control one’s end-of-life care, particularly because the technical language used in a living will is challenging.  Establishing an easy access to a living will written in an easy-to-understand language, such as Five Wishes, is recommended.