Advance care planning documentation allows individuals to communicate preferences for medical care and designate surrogate decision-makers. It is unknown if comprehensive documentation confers additional benefits.
Objectives
This study examined additive associations between comprehensive advance care planning (ACP) documentation and end-of-life care (EOL) outcomes among older adults in the United States.
Setting/Subjects
Data from the Health and Retirement Study exit interviews (2010-2022) indicated ACP documentation status, based on proxy-reported completion of a living will (LW) and/or durable power of attorney (DPOA) for 5622 decedents representing 23.2 million individuals.
Measurement
Documentation was operationalized as a binary variable (any document, no document) and an ordinal variable (no documentation, one document, two documents). EOL outcomes included binary indicators of intensive care unit use in the last two years of life, use of life-sustaining treatments, hospice utilization prior to death, and location of death (out-of-hospital, hospital).
Results
About 42.7% decedents had two documents and 28.9% had none, documentation increased substantially around 2014. Compared with no documentation, having any documentation was associated with lower likelihood of life-sustaining treatment (aRR = 0.85, 95% CI: 0.74-0.98) and higher likelihood of hospice utilization (aRR = 1.43, 95% CI: 1.28-1.60) and out-of-hospital death (aRR = 1.11, 95% CI: 1.06-1.18), but not ICU use. Having two documents showed similar patterns. Associations were stronger among decedents with expected death and attenuated among those with unexpected death.
Conclusions
ACP is associated with less aggressive EOL care and greater hospice use, although the incremental benefits of having both documents are modest.
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