Going It Alone: Advance Directive Discordance in Older Married Couples

Abstract

Contrary to expectations of joint decision-making, a substantial minority of older married couples report only one spouse possessing an advance directive. Using Health and Retirement Study data, the authors examined advance directive discordance among heterosexual married couples in which at least one spouse had completed an advance directive. It was predicted that spouses who differed in age, self-rated health, or race/ethnicity would be more apt to adopt individualistic as opposed to relational motivational stances, resulting in higher odds of nonmatching advance directive status. Heterogamy did not account for discordance, but couples in which one or both spouses attended some college were more likely to report advance directive concordance. In contrast, couples in which one or both spouses were non-White were more likely to display advance directive discordance. Study results raise concerns about the effectiveness and reach of advance care planning promotion efforts among low-education and non-White older married adults.

Keywords

advance care planning/directives decision-making risk perception self-rated health end of life

Introduction

Approximately 40% of older adults in the United States require surrogate decision-making at the end of life because they become unable to formulate or articulate instructions about their medical treatment (Silveira, Kim, & Langa, 2010). When no information about a person’s preferences is available, the general legal presumption is that the individual would choose to receive all medical care necessary to sustain life (Institute of Medicine [IOM], 2015). However, if a person communicates preferences about future life-sustaining treatment while still competent, this presumption no longer applies, and the patient’s expressed wishes should guide medical decisions. The process of considering and communicating future health care preferences is called advance care planning (ACP).

ACP frequently results in an advance directive. The format of this legal document varies but usually consists of two parts: a living will and a durable power of attorney for health care (IOM, 2015). The living will allows individuals to state in writing what medical treatments they would or would not wish to receive under certain conditions such as a persistent vegetative state or irreversible and severe cognitive impairment. The durable power of attorney for health care is used to formally designate one or more health care proxies to act on one’s behalf in the event of incapacity (IOM, 2015).

Approximately half of U.S. adults age 65 or older have advance directives (Pew Research Center, 2009; Rao, Anderson, Lin, & Laux, 2014). Advance directive completion is associated with a reduction in life-sustaining interventions at the end of life, particularly intubation and cardiopulmonary resuscitation (CPR) (Brinkman-Stoppelenburg, Rietjens, & van der Heide, 2014; Teno, Gruneir, Schwartz, Nanda, & Wetle, 2007; Tschirhart, Du, & Kelley, 2014). Among patients at high risk of death, having an advance directive decreases the odds of intensive care unit (ICU) admission and is associated with shorter ICU stays (Khandelwal et al., 2015). Patients who possess advance directives are more likely to be admitted to hospice and to receive hospice care for longer periods of time before death (Bischoff, Sudore, Miao, Boscardin, & Smith, 2013; Brinkman-Stoppelenburg et al., 2014; Greiner, Perera, & Ahluwalia, 2003; Teno et al., 2007).

A growing body of research uses the transtheoretical model (TTM) to illustrate how people move through stages of increasing awareness of and motivation to engage in ACP (Fried, Bullock, Iannone, & O’Leary, 2009; Fried et al., 2010, 2012; Medvene, Base, Patrick, & Wescott, 2007; Moorman & Inoue, 2012; Rizzo et al., 2010). Most of these studies have treated advance directive completion as an individual health behavior. However, it is important to understand the roles that family members may play in informing, encouraging, or preventing loved ones’ engagement in ACP (Boerner, Carr, & Moorman, 2013; Moorman, Carr, & Boerner, 2014; Woosley, Danes, & Stum, 2017).

The marital relationship in particular is a potentially important social context in which ACP takes place. The majority of older adults are married during at least a portion of their later years (Administration on Aging Administration for Community Living, 2014). Spouses and partners tend to exert informal control to regulate and shape life trajectories (Elder & Shanahan, 2006). Married persons lead linked lives across intertwined life courses and develop shared patterns of behavior and attitudes that influence their own and one another’s decisions and actions (Bourassa, Memel, Woolverton, & Sbarra, 2015; Elder & Shanahan, 2006). Married couples share information and make choices together that include where to live and work, and whether to have children and how to raise them. Medical decisions, in particular, frequently have consequences for both spouses and are often the result of consultative or joint decision-making processes (Haley et al., 2002; Rettig, 1993).

There is extensive research on similarities in spousal health behaviors and outcomes. Spouses’ actions, perceived relationship quality, and goals have been shown to influence their partners’ actions and perceptions as well as health and well-being (Hoppmann & Gerstorf, 2009; Meyler, Stimpson, & Peek, 2007). Assortative mating, common environment and social networks, pooled resources, and spousal pressure, among others, have been postulated to contribute to marital concordance in preventive behaviors such as smoking cessation, exercise, diet, screenings, and vaccinations (Falba & Sindelar, 2008).

To explain differences in how spouses influence one another’s health decisions, Lewis and colleagues (2006) proposed a dyadic health behavior change model that accounts for the varying degrees of interdependence of couples’ motivations and coping behaviors. According to this model, health behavior change is motivated by a combination of individual, partner, and joint factors. Patterns of interdependence (i.e., the degree to which choices are influenced by individual, partner, and joint factors) depend in part on to what extent each spouse has adopted an individual or relational motivational orientation. The degree of transformation from individual to relational motivation may vary based on, among other factors, perceptions of overlapping interests. Spouses who share common health goals and values are more likely to adopt a relational motivational perspective, be mutually influential on one another’s health behaviors, and move through the stages of health behavior change jointly. In contrast, spouses with differing health priorities or values are more likely to retain individualistic motivational stances, be influenced primarily by individual factors, and move through the stages of health behavior change independently of one another.

Relatively little research has been conducted to examine how spouses or partners may influence ACP. Koss (2017) found significant actor and partner effects of age, education, self-rated health, and health care utilization on advance directive possession by older married adults. Marital satisfaction appears to be positively associated with advance directive completion as well as end-of-life discussion by married adults (Carr, Moorman, & Boerner, 2013; Moorman et al., 2014). However, Boerner and colleagues (2013) found no significant relationship between spousal criticism, emotional support, or marital duration and advance directive completion.

The advance directive statuses of spouses are correlated, but there is a substantial minority of couples with discordant advance directive completion (Koss, 2017). To engage in written ACP independently of one’s spouse suggests a level of individualization that challenges assumptions of marital interdependence, relational motivation, and shared decision-making (Yodanis & Lauer, 2014). In addition, it highlights decision-making processes which involve an individual’s or couple’s readiness for change. This study begins to identify circumstances under which couples are more likely to display individualization in end-of-life planning versus interdependent decision-making.

One potential explanation for individualization in ACP is heterogamy. Spouses who differ from one another, particularly on characteristics predictive of ACP, may be more likely to maintain an individualistic motivation orientation and complete advance directives independently of their partners. This study considers four types of heterogamy: age, self-rated health, race/ethnicity, and education.

Age

Older age is positively associated with advance directive completion (Rao et al., 2014). Partners who are of significantly different ages occupy different places in the life course. Younger spouses may perceive themselves as too young to need advance directives, a commonly identified barrier to engaging in ACP (Schickedanz et al., 2009). When the older spouse reaches a point when ACP is personally relevant, he or she may decide to complete an advance directive alone rather than wait until the younger spouse is ready. Significant age differences may also potentially lead to higher levels of marital conflict or more contentious decision-making processes (Choi & Vasunilashorn, 2013; Pyke & Adams, 2010). Therefore, we hypothesized the following:

Hypothesis 1 (H1): Couples in which one spouse was significantly older than the other would have greater odds of advance directive discordance.

Health Status

Several studies suggest that poorer overall health is associated with greater odds of advance directive completion (Bischoff et al., 2013; Rao et al., 2014). In qualitative studies, a common reason given for not completing an advance directive is the perception of being too healthy to need one (Cugliari, Miller, & Sobal, 1995; Schickedanz et al., 2009). Like age, a less healthy spouse may choose to complete an advance directive alone rather than wait until the healthier spouse is ready. Therefore, we hypothesized the following:

Hypothesis 2 (H2): Couples in which one spouse was in worse health than the other would have greater odds of advance directive discordance.

Race/Ethnicity

Rates of advance directive completion are lower among non-White older adults due to socioeconomic and cultural factors (Carr, 2011; Koss & Baker, 2018; Sanders, Robinson, & Block, 2016). Spouses from different cultural backgrounds may be less aligned in their health values or priorities, resulting in more individualistic motivational stances. White older adults in interracial marriages may also face fewer cultural barriers to ACP than their non-White spouses. We hypothesized the following:

Hypothesis 3 (H3): Couples in which only one spouse was non-Hispanic White would have greater odds of advance directive discordance.

Education

Higher education increases the odds of engaging in written ACP (Boerner et al., 2013; Koss & Baker, 2018; Rao et al., 2014). Unlike age, health status, and race/ethnicity, we treated education as a pooled marital resource because the education of each spouse, especially the husband’s, often influences both spouses’ financial status, health, and decision-making (Brown, Hummer, & Hayward, 2014; Crystal, Shea, & Krishnaswami, 1992; Koss, 2017; Ornstein et al., 2016). Individuals with higher education may seek information about ACP more proactively (Smith, Dixon, Trevena, Nutbeam, & McCaffery, 2009). To the extent spouses share information, higher education of one spouse may result in greater awareness of ACP by both spouses. Those with postsecondary education are also more likely to complete advance directives as part of financial or estate planning, often with the assistance of an attorney (Carr, 2012; Kelly, Masters, & Deviney, 2013; Su, 2008). Estate planning involves decisions about jointly-owned financial resources and is therefore generally engaged in by spouses together. In contrast, older adults who engage in ACP outside of the estate planning process, such as during encounters with health care providers, may be more likely to receive information and assistance separately from their spouses. We therefore hypothesized the following:

Hypothesis 4 (H4): Couples in which neither spouse had attended college would be more likely to have discordant advance directive statuses.

We also examined which spouse was more likely to possess an advance directive among a subset of couples with discordant ACP. Consistent with prior studies that have found written ACP to be associated with older age, poor health, higher education, and being non-Hispanic White (U.S. Government Accountability Office, 2015), we predicted that the spouse with an advance directive within heterogamous couples would more likely be the older spouse, the spouse in poorer health, the spouse with more education, or the non-Hispanic White spouse. We anticipated approximately equal distribution of advance directive completion between husbands and wives among homogamous couples.

Method

Sample and Data

Research was conducted using data from the 2014 wave of the U.S. Health and Retirement Study (HRS), a longitudinal survey of older adults sponsored by the National Institute on Aging (Grant NIA U01AG009740) and administered by the University of Michigan.

Data were extracted for a subsample of heterosexual married couples in which both spouses were at least 65 years old and residing in the 50 United States. Only dyads in which at least one spouse reported possessing a living will and/or durable power of attorney for health care in 2014 were included.

Measures

Dependent variable

Advance directive status was measured with two questions about completion of a living will and of a durable power of attorney. Participants were asked, “Have you made any legal arrangements for a specific person or persons to make decisions about your care or medical treatment if you cannot make those decisions yourself? This is sometimes called a ‘Durable Power of Attorney for Health Care.’” and “Have you provided written instructions about the care or medical treatment that you want to receive if you cannot make those decisions yourself? This is sometimes called a ‘Living Will.’” Participants who responded positively to either question were coded as having an advance directive. The combination of these variables is consistent with prior research as well as the Patient Self-Determination Act (1990) definition of an advance directive as a written instruction such as a durable power of attorney or living will. A couple-level dichotomous variable was constructed indicating whether only one spouse (discordance) or both spouses (concordance) reported having an advance directive.

Predictor variables

Dummy-coded variables indicated whether the husband was three or more years older than the wife, the wife was three or more years older than the husband, or the spouses’ ages were within two years of one another. Self-rated health was coded as either fair or poor or as good, very good, or excellent. Race/ethnicity was coded as non-Hispanic White or non-White. Education was coded as either high school or less or at least some college. These dummy codes were used to categorize couples into age heterogamy profiles based on which spouse was older, health heterogamy profiles based on who was in fair or poor health, race/ethnicity heterogamy profiles based on who was non-Hispanic White, and education heterogamy profiles based on who lacked secondary education.

Control variables

Ages (in years) of husbands and wives, whether or not spouses had been married previously, duration (in years) of current marriage, and household income (log-transformed) were included as control variables.

Analyses

Descriptive statistics were generated for individual participants (stratified by gender) and couples. Logistic regression models were used to examine associations between couple advance directive discordance and age, health status, race/ethnicity, and education heterogamy profiles, controlling for age, marital duration, remarriage, and household income. Models were run with data for all couples (Model 1), for couples in which the husband possessed an advance directive (Model 2), and for couples in which the wife possessed an advance directive (Model 3). Pearson χ² tests were used to examine advance directive distribution among the 27% of couples in which only one spouse had an advance directive, stratified by age, health status, race/ethnicity, and education heterogamy profiles. All analyses were conducted using Stata version 14.2 (StataCorp, College Station, TX).

Ethical Considerations

This study was exempted from institutional review by the California State University, Sacramento Institutional Review Board.

Results

Descriptive statistics are reported in Table 1. A total of 1,612 couples met the inclusion criteria. Eleven couples were dropped from the sample due to missing data.

Table 1.

Sample Characteristics.

Variable	Men (n = 1,601)	Women (n = 1,601)	Couples (n = 1,601)
Advance directive completion (%)	87	86
Both spouses			72
Husband only			14
Wife only			13
Age, M (SD)	77.2 (6.4)	74.4 (6.3)
Age difference (%)
Spouses’ ages within 2 years			45
Husband 3+ years older			49
Wife 3+ years older			6
High school or less (%)	46	50
Both spouses			33
Neither spouse			37
Husband only			13
Wife only			17
Fair/poor self-reported health (%)	27	22
Both spouses			8
Neither spouse			59
Husband only			19
Wife only			14
Non-White (%)	14	14
Both spouses			12
Neither spouse			84
Husband only			2
Wife only			2
First marriage (%)	70	70
Both spouses			65
Neither spouse			25
Husband only			5
Wife only			5
Years married, M (SD)			45.6 (15.9)
Median household income ($)			55,025

Roughly equal percentages of men (87%) and women (86%) had advance directives, with 27% of the couples reporting advance directive discordance. By design, there were no couples in which both spouses lacked advance directives. On average, men were three years older than women, with a mean age of 77.2 years compared with 74.4 for women. Men were three or more years older than their spouses in almost half of the couples, whereas couples in which women were three or more years older were relatively rare (6%). In terms of health, 27% of men and 22% of women rated their health as fair or poor. A third of the couples displayed self-rated health heterogamy. Non-Hispanic White participants made up 86% of the sample for both genders. Only 4% of couples consisted of one White and one non-White spouse. Half of the women and 46% of the men had never attended college. Education heterogamy was present in 30% of couples.

Results from three logistic regression models are presented in Table 2. In Model 1, analysis was conducted using data from all 1,601 dyads. Contrary to what was predicted in H1 and H2, there were no significant effects for the age or health status heterogamy profiles. Compared with couples in which both spouses were White, the odds of only one spouse possessing an advance directive were more than double when only the husband was White (odds ratio [OR] = 2.39, p < .05) or when only the wife was White (OR = 2.47, p < .05). These results are consistent with H3. However, the odds of advance directive discordance were more than triple when neither spouse was White (OR = 3.61, p < .001). Consistent with H4, couples in which both spouses had never attended college were almost twice as likely to have nonmatching advance directive statuses (OR = 1.83, p < .001).

Table 2.

Logistic Models Regressing Advance Directive Discordance on Age, Education, Self-Rated Health, Race/Ethnicity, Marital History, and Household Income.

Variable	Model 1 (all) (N = 1,601)	Model 2 (H has AD) (n = 1,382)	Model 3 (W has AD) (n = 1,369)
Variable	OR [CI]	OR [CI]	OR [CI]
Age heterogamy
Ages w/in 2 years (ref.)	—	—	—
Husband 3+ older	0.73^† [0.51, 1.04]	0.47** [0.30, 0.75]	1.11[0.70, 1.77]
Wife 3+ older	1.47[0.82, 2.65]	1.29[0.55, 3.03]	1.40[0.67, 2.94]
High school or less
Neither spouse (ref.)	—	—	—
Husband only	1.39^† [0.95, 2.05]	1.13[0.68, 1.89]	1.85* [1.13, 3.05]
Wife only	1.29[0.90, 1.85]	1.51^† [0.96, 2.38]	1.01[0.60, 1.70]
Both spouses	1.83*** [1.35, 2.54]	1.69** [1.23, 2.55]	2.14*** [1.41, 3.25]
Fair/poor health
Neither spouse (ref.)	—	—	—
Husband only	0.91[0.66, 1.25]	1.21[0.81, 1.78]	0.65^† [0.41, 1.04]
Wife only	1.12[0.78, 1.59]	0.82[0.49, 1.35]	1.40[0.91, 2.15]
Both spouses	1.21[0.78, 1.89]	1.01[0.55, 1.86]	1.43[0.84, 2.43]
Non-Hispanic White
Both spouses (ref.)	—	—	—
Husband only	2.39* [1.16, 4.92]	3.02** [1.32, 6.93]	1.70[0.59, 4.86]
Wife only	2.47* [1.20, 5.07]	1.56[0.58, 4.23]	4.29** [1.85, 9.94]
Neither spouses	3.61*** [2.58, 5.05]	3.26*** [2.14, 4.97]	3.89*** [2.58, 5.88]
Age
Husband age	1.02[0.97, 1.07]	1.09** [1.02, 1.15]	0.95[0.89, 1.02]
Wife age	0.91*** [0.86, 0.96]	0.83*** [0.78, 0.89]	1.00[0.93, 1.07]
Remarriage
Neither spouses (ref.)	—	—	—
Husband only	1.61^† [0.94, 2.72]	1.57[0.80, 3.05]	1.68[0.83, 3.40]
Wife only	1.72* [1.01, 2.92]	1.39[0.69, 2.83]	2.05* [1.06, 3.95]
Both spouses	1.06[0.64, 1.74]	0.97[0.51. 1.84]	1.14[0.59, 2.21]
Years married	1.00[0.98, 1.03]	1.00[0.98, 1.02]	1.00[0.98, 1.02]
Log income	0.94[0.79, 1.12]	0.92[0.74, 1.14]	0.96[0.77, 1.21]

Note. H = husband; AD = advance directive; W = wife; OR = odds ratio; CI = confidence interval.

†

p < .10. *p < .05. **p < .01. ***p < .001.

Model 2 analyzed data from couples in which all men had advance directives and calculated the odds of their wives not also possessing advance directives (discordance) (n = 1,382). Contrary to H1, men who were three or more years older than their spouses were significantly less likely to be the sole possessor of an advance directive (OR = .47, p < .001) compared with age-homogamous couples. Likewise, H2 was not supported by the data, as there were no significant effects for the health status profiles. H3 was only partially supported. Men who were married to non-White women were more than three times as likely to be the sole advance directive completer both when the men were White (OR = 3.02, p < .01) and not (OR = 3.26, p < .001). Men were more likely to be the only person in the couple with an advance directive when neither spouse had ever attended college (OR = 1.69, p < .001), consistent with H4.

Model 3 analyzed data from couples in which all of the women had advance directives and calculated the odds of their husbands not also possessing advance directives (discordance) (n = 1,369). Neither H1 nor H2 was supported by the data, as there were no significant effects for the age or health status profiles. H3 and H4 were only partially supported. Women married to non-White men were approximately four times as likely to be the only person in the couple with an advance directive when the woman was also non-White (OR = 3.89, p < .001) and when the woman was White (OR = 4.29, p < .01). Women married to men who never attended college were more likely to be the sole possessor of an advance directive both when the women also lacked postsecondary education (OR = 2.14, p < .001) or if they had attended college (OR = 1.85, p < .05).

Pearson χ² tests were used to examine which spouse had completed an advance directive in the 446 couples with discordant advance directive statuses, stratified by the heterogamy profiles. Our prediction that advance directive distribution would be evenly divided between spouses in homogamous couples and weighted toward the older, less healthy, non-Hispanic White, and more educated spouse in heterogamous couples was generally supported by the data with some exceptions and gender differences.

As Figure 1 illustrates, distribution of advance directives significantly differed by age profile (χ² = 6.79, p = .034). Advance directive completion was fairly evenly divided between men and women in couples with age homogamy and for couples in which the husband was three or more years older than the wife. However, in couples in which wives were three or more years older than their husbands, women completed advance directives in just more than 70% of the dyads.

Figure 1.

Spousal distribution of advance directive possession in couples with discordant advance directive status, by age difference profile (n = 446).

Although self-rated health was not predictive of advance directive concordance in the logistic regression models, it was significantly associated with advance directive distribution in couples with nonmatching advance directive statuses (χ² = 12.28, p = .006). In couples with heterogamous health statuses, the spouse in fair or poor health tended to have the advance directive. More women than men possessed advance directives among couples in which both spouses reported fair or poor health (Figure 2).

Figure 2.

Spousal distribution of advance directive possession in couples with discordant advance directive status, by health status profile (n = 446).

There was no statistically significant effect of race/ethnicity on advance directive distribution. This may be due to the low number of interracial couples, resulting in small cell counts. One can observe from the graph (Figure 3) that, among the few interracial couples, the White spouse tended to be the one to possess the advance directive, whereas the distribution was evenly split between husbands and wives in racially homogamous couples.

Figure 3.

Spousal distribution of advance directive possession in couples with discordant advance directive status, by race/ethnicity profile (n = 446).

Figure 4 illustrates the distribution of advance directive completion in couples with different education profiles. Overall, the spouse with more education tended to be the one possessing the advance directive, but these effects were fairly small and only approached statistical significance (χ² = 6.59, p = .086).

Figure 4.

Spousal distribution of advance directive possession in couples with discordant advance directive status, by education profile (n = 446).

Discussion

This study sought to identify factors that lead some older married couples to display individualization in end-of-life planning rather than interdependent or joint decision-making. Based on the dyadic health behavior model (Lewis et al., 2006), we proposed that heterogamy in characteristics associated with ACP would impede the transition from individual to relational motivation, resulting in greater odds of advance directive discordance. We hypothesized that couples who differed in age, health status, or race/ethnicity would be more likely to display discordant advance directive completion. We predicted that couples in which both spouses had low levels of education would be more likely to have nonmatching advance directive statuses. Among couples with discordant advance directive completion, we anticipated that the spouse who was older, was non-Hispanic White, had higher education, or was in poorer health would be the one to possess the advance directive.

The first three hypotheses were not supported by the data. Neither age nor health heterogamy significantly increased the odds of advance directive discordance. In fact, compared with similarly aged spouses, discordance was less likely among couples in which men possessed advance directives and were three or more years older than their spouses. Race/ethnicity was strongly predictive of advance directive discordance, but this was true in both racially heterogamous and homogamous couples. These results suggest that heterogamy may not increase individualization or be the underlying reason for advance directive discordance.

The fourth hypothesis was supported by the data. Advance directive discordance was more likely in couples in which both spouses lacked postsecondary education. The findings are consistent with the view of education as a pooled resource facilitating ACP by both spouses, but with one important exception. Women were more likely to “go it alone” when they were married to someone who had never attended college, regardless of their own educational attainment. Men may be less influenced in their ACP behaviors by their wives’ educational attainment than vice versa. These results are consistent with previous research finding that men’s educational attainment exerts a stronger influence on both their own and their spouses’ advance directive completion than women’s education (Koss, 2017).

Among couples with advance directive discordance, the distribution of advance directives was generally consistent with predicted patterns. In heterogamous couples, the spouse with worse health tended to be the one possessing an advance directive. Consistent with the TTM framework, poorer health may increase readiness, whereas more healthy individuals may dwell in precontemplation and never move to a higher order of planning. The effects of education were only marginally significant but suggest a modest tendency for the spouse with more education to be the one with a directive. The spouse who was non-Hispanic White also tended to have the advance directive, although low cell counts make interpreting the significance of these results problematic. Women who were three or more years older than their spouses tended to be the advance directive completers, but this was not the case for older husbands.

Some limitations of this study should be acknowledged. Advance directive status was self-reported, and some participants may have been mistaken about what planning documents they had completed. Data about the timing or context of ACP were not available. It is therefore possible that some spouses may have both possessed advance directives when surveyed but completed them separately or at different times. The small number of couples in certain heterogamy profiles, particularly interracial couples and couples in which the woman was older than the man, may have resulted in insufficient power to detect some effects.

This study highlights some of the factors that may contribute to marital individualization in the form of completing an advance directive separately from one’s spouse. Low education of both spouses and non-White race/ethnicity of one or both spouses were the significant predictors of advance directive discordance. As discussed in the introduction, prior studies have observed education disparities in estate planning. These and other studies have also observed race/ethnicity disparities in estate planning, with non-White older adults being less likely to have a will or trust (AARP, 2000; Carr, 2012; Koss & Baker, 2018). Couples in which one or both spouses are non-White may be less likely to engage in estate planning. Consequently, the ACP of one spouse may be more likely to occur in a setting separate from the other spouse.

Efforts to promote advance directive completion are less efficient when they reach only one spouse. Special effort should be made to assist the patient or client not just to complete an advance directive, but also to educate and encourage the patient’s spouse or partner to engage in ACP. The TTM may be a useful tool to spark discussions between partners about barriers to completing ACP.

These results also add to robust existent evidence of race/ethnicity disparities in ACP by demonstrating that non-White older adults are less likely to complete advance directives even when their spouses have engaged in written ACP. The fact that discordance is more likely among couples with low educational attainment and who are non-White is particularly troubling given overall low rates of ACP among these groups.

Individualization in ACP may also indicate a lower level of spousal consultation about end-of-life treatment choices. It is critical that spouses are aware of one another’s wishes, discuss their concerns, and come to terms with one another’s expressed preferences. Lack of knowledge, understanding, or acceptance by one spouse may lead to familial conflict and distress if and when end-of-life care decisions must be made. Although beyond the scope of this study, whether and to what extent advance directive discordance is associated with less spousal consultation or communication regarding end-of-life decisions is an important topic for future research.

Even though age, health, and race/ethnicity heterogamy were not found to increase the odds of advance directive discordance in this study, other spousal differences may help explain advance directive discordance, such as religiosity, death anxiety, or prior experience making health care decisions for others. Future studies may also deepen our understanding of the reasons for spousal advance directive discordance by testing the role that the context in which ACP takes place (health care, legal, or other) may play.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Donna Jensen

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