What Matters for Completion of Advance Directives Among American Older Adults?

Background and Purpose: Advance directives allow people to specify their medical preferences when they are no longer able to make decisions. Most previous studies consider advance directives as one single outcome, which conceals possible variations of individuals’ decisions on two different advance directives documents–living will (LW) and durable power of attorney for healthcare (PA). In fact, many older adults in the United States only have one of them. To advance the knowledge on advance planning among older adults in the US, this study examined how health status and education are associated with completions of LW and PA and whether such associations vary by age and race.

Methods: Data are from 2016 Health and Retirement Study Core (Early, Version 2.0). The sample includes 9,830 elders who completed Wills, Insurance and Trusts Module. Health status was indicated by chronic condition and ADL and IADL functional limitations. Education is measured by the year of education received. Logistic regression model was used to examine how the completions of LW and PA are associated with health and education variables respectively. Interaction terms were created to test the moderating effects of race and age.

Results: The analysis results show that the older adults with only living will have statistically significant lower age, lower ADL limitation, higher education, and different racial group, compared to those with only power attorney. Elders with higher IADL functional limitation and more education were more likely to complete completing wither or PA or LW. Being white and higher age will increase the probability for an older adult to complete PA, whereas the older adults with heart problem were more likely to complete LW. The association between IADL/ADL and PA was stronger in white than other racial groups, and the association between IADL and LW was stronger in young-old than the oldest-old.

Conclusions and Implications: The findings highlight the importance of examining the completions of two advance directive documents respectively and indicate the necessity of developing distinct and concrete strategies to promote the completions of PA and LW. Purposed suggestions to front-line social work field include: 1) having only PA and no LW may cause patients to relinquish their power and control over their bodies to the surrogates, so medical social workers in the hospital settings should educate the patients on the difference between the two documents with a special attention to LW; 2) community social workers should be aware that education program regarding advance care planning needs to target young-old population and home-bound elders with ADL or IADL functional limitations as early as possible; and 3) intervention program should be culturally-sensitive to different racial and ethical groups.