Change of Health Conditions and Uptake of Advance Care Planning: Moderating Role of Race/Ethnicity

Background: Advance care planning (ACP), or the formal steps taken to convey one’s preferences for end-of-life care, is a critical step toward a “good death” marked by treatment consistent with the wishes of the patients. The need for ACP is heightened during the COVID-19 pandemic, especially for older Blacks and Latinx persons who are at a disproportionate risk of death from both infectious and chronic disease. However, only 30-percent of older adults have ACP with well-documented racial disparities. It is important to explore motivations behind older adults’ ACP uptake across older adults with different racial/ethnic backgrounds in order to design effective interventions. Thus, this paper aims to investigate health change as a potential trigger of ACP uptake, based on prospect theory. The paper also aims to answer whether the effects of change in health conditions on older adults’ ACP uptake are immediate or lagged and whether the effects varied by race/ethnicity.

Method: Data are from Health and Retirement Study 2012 to 2018. Samples are 7,097 older adults who didn’t engage in any of three ACP behaviors (living will (LW), durable power of attorney for health care (DPAHC), and discussions) in 2012. Uptake of those three ACP aspects were tracked in 2014, 2016, and 2018. Health change is proxied by 11 factors including decline in self-reported health, decline in activities of daily living (ADL), increase in pain levels, and receiving a new diagnosis of cancer, hypertension, diabetes, lung, heart, stroke, and arthritis since 2012. Logistic regression models were used to estimate 1) the effects of health change from 2012 to 2014 on ACP uptake in 2014, 2016, 2018, respectively and 2) heterogeneous effects by using interaction terms between health change and race/ethnicity.

Results: We found that older adults with ADL decline were more likely to document DPAHC and LW and discuss their wishes with their family members in 2012, while decline in self-reported health didn’t motivate older adults to initiate any of the ACP behavior within two years of health change. Older adults who have experienced more pain in the last two years were likely to document and discuss end-of-life care wishes. Had cancer diagnosis motivated older adults to document LW within two years of diagnosis, while had stroke problem in the last two years motivated them to document DPAHC. Changes in health conditions in general didn’t have a long-term effect on ACP uptake. Multiple indicators of health changes (declines in ADL and IADL functioning and pain) were related to ACP behaviors in white older adults, whereas fewer health indicators shaped the likelihoods of filing DPAHC and LW among black and Hispanics.

Implications: We found several indicators of health change that may motivate older adults to engage in ACP. Practitioners may prompt ACP discussions with older adults once their clients have experienced health changes and follow up ACP along their health trajectory. When working with minorities, clinical practitioners need to consider patients’ cultural, psychological and social readiness to discuss or file DPAHC and LW and their preferred process of developing ACP.