End-of-Life Issues Not Addressed by Majority of
Age, race, education level, and health status impact
advance directive completion
December 10, 2013 – During the past two decades,
high-profile legal cases surrounding end-of-life decisions have received
widespread attention in the United States, prompting increased media
focus and numerous debates on the subject. Despite this continuing
nationwide dialogue, many Americans still tend to avoid addressing their
own end-of-life (EOL) issues, including the completion of advance
In a new study published in the American Journal
of Preventive Medicine, a group of investigators examined the
factors associated with advance directive completion.
Although various national polls and selected state
surveys provide some insight into American attitudes about advanced
directives, there is a lack of population-based data regarding advance
directive completion among adults.
For this study, investigators analyzed data from
the 2009 and 2010 Porter Novelli HealthStyles national surveys, which
included EOL and advance directive-specific questions.
The team looked at responses from 7,946
participants in the HealthStyles survey and found that only 26.3% had
completed an advance directive.
The data showed that advance directives were more
frequent among women, whites, respondents who had a college degree or
postgraduate training, or were married. Respondents with advance
directives also were more likely to report having a chronic disease and
a regular source of care.
The study shows significant associations
between completing an advance directive and age, income, education, and
"For black and Hispanic respondents, advance
directives were less frequent across all educational groups. These data
indicate racial and educational disparities in advance directive
completion and highlight the need for education about their role in
facilitating EOL decisions," explains Jaya K. Rao, MD, who, at the time
the work was performed, was an Associate Professor in the Division of
Pharmaceutical Outcomes and Policy at the Eshelman School of Pharmacy,
University of North Carolina.
For respondents who had never completed an advance
directive, investigators found that the most frequently reported reason
for not having one was lack of awareness.
"The study provides information from a large sample
of adults on their attitudes and behaviors regarding advance
directives," says Lynda A. Anderson, PhD, Director, Healthy Aging
Program, National Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and Prevention.
"Prior studies have focused on clinical
populations, state samples, or certain age groups. People who lack the
knowledge to have EOL concerns or discussions or about the role of
advance directives in facilitating EOL decisions may represent potential
targets for intervention."
While several investigations have shown that health
care costs are greatest during the final years of life, researchers
found that the use of advance directives was associated with lower
levels of Medicare spending and a lower likelihood of in-hospital
"Given the current discussions about implementing
various models of health care delivery, including the patient-centered
medical home, EOL issues need to come to the forefront of planning
efforts," adds Dr. Rao. "Hopefully, these findings will contribute to
the current national conversations about EOL care."
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