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 directives. 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 health status.

“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 deaths.

“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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Beverly Lytton
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Elsevier Health Sciences