Racial Differences in End of Life Preparation Among Older Adults

Background: End of life preparation is recommended for people of all ages and activities such as discussing end of life care, assigning power of attorney and creation of a living will are associated with end of life preparation/advance care planning. Significant racial disparities in health care outcomes and access to services between Whites and minorities have been observed and these differences have been attributed to a variance in cultural values, socio-economic status and knowledge of advanced directives. Guided by the Andersen model of healthcare utilization, the aim of this study was to analyze racial differences in End of Life preparation among a nationally-representative sample of older adults, while considering the influence of predisposing, enabling and need factors.

Methods: This cross-sectional study utilized data from the 2018 National Health and Aging Trends Study, which is a nationally representative sample of older adults. A sample of 1326 older adults reported on end of life care preparation as operationalized in the study, and statistical analysis were weighted to account for differential selection probabilities and non-response bias. Chi square tests were used to analyze group differences and a binary logistic regression was used to predict probability of end of life preparation.

Results: Results shows that when predisposing, enabling and need factors are accounted for, Whites were significantly more likely to discuss end of life care than Blacks (OR=1.9) and Hispanics (OR=2.6). Whites were also more likely to discuss power of attorney than Blacks (OR=1.9) and Hispanics (OR=2.6). Finally, Whites were three times more likely to have a living will than Blacks (OR=3.0) and Hispanics (OR=3.2). These findings were significant even when socio-demographic, social capital and health factors are considered.

Conclusion: These results point to significant racial disparities in end of life preparation among older adults and mirror the homogeneous composition of older adults in hospice, palliative and end of life care. This calls for an examination of these differences using race theories as opposed to the typical social determinants of health that are attributed to racial differences across the lifespan. Further implications for social work practitioners, researchers and policymakers are discussed.