Abstract
Advance care planning (ACP) is widely considered an essential step toward achieving end-of-life care that is consistent with the preferences of dying patients and their families. ACP comprises a living will and a durable power of attorney for health care (DPAHC); these tools enable patients to articulate and convey their treatment preferences when they are still cognitively intact. In this article, we describe the strengths, weaknesses, and correlates of ACP in the United States, with attention to race and socioeconomic disparities therein. We then discuss other public policies and community programs designed to increase both the number of older adults who articulate their preferences for end-of-life care, and efficacy of ACP for ensuring that patients’ end-of-life treatment preferences are met. We describe the characteristics, strengths, and limitations of Physician Orders for Life Sustaining Treatment (POLSTs), and describe community programs, educational interventions, and public policies aimed toward increasing the prevalence and efficacy of end-of-life preparations. A key policy advance in the early 2010s has been Medicare coverage of one doctor–patient consultation session regarding end-of-life issues; we highlight the potentials and possible pitfalls of this policy. We conclude by identifying areas for future research, and highlighting practices from other nations that may help improve quality of end-of-life care in the United States.
Highlights
Translational Significance: Advance care planning (ACP) is linked with greater use of palliative care among dying patients, lower medical expenditures at the end of life, and less distress among patients and their family members
We discuss other public policies and community programs designed to increase both the number of older adults who articulate their preferences for end-of-life care, and efficacy of ACP for ensuring that patients’ end-of-life treatment preferences are met
Strengths, and limitations of Physician Orders for Life Sustaining Treatment (POLSTs), and describe community programs, educational interventions, and public policies aimed toward increasing the prevalence and efficacy of end-of-life preparations
Summary
ACP is intended to improve the quality of death for all Americans, yet in practice, it is largely undertaken by older adults of higher versus lower socioeconomic status (SES), Whites versus Blacks, and socially integrated versus isolated older adults. But most research finds that Whites are two to three times as likely as Blacks and Latinos to have an advance directive, with a much narrower gap for end-of-life discussions (Carr, 2011) These disparities have declined considerably over the past decade (Koss & Baker, 2017a). Research shows stark race and socioeconomic disparities in formal ACP but not informal discussions – an activity that can be undertaken at no financial cost, and that does not require interactions with health care or legal professionals (Carr, 2012b) These patterns suggest that economic, informational, and structural barriers may be a more daunting obstacle to end-oflife planning among ethnic minorities and poorer adults than are cultural or attitudinal factors. We describe recent innovations to promote ACP, highlighting the extent to which these approaches may be effective in increasing ACP rates of all older adults, rather than just the most advantaged
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