English- and Spanish-Speaking Vulnerable Older Adults Report Many Unique Barriers to Advance Care Planning (W215A)

Abstract

1.Identify common barriers to advance care planning for diverse English- and Spanish-speaking older adults.2.Recognize which vulnerable subpopulations report the most barriers to advance care planning.3.Recognize that barriers to advance care planning are associated with lower rates of ACP documentation (e.g. advance directive, POLST). Advance care planning (ACP) rates are low in diverse, vulnerable older adults, yet little is known about the unique barriers they face and how these barriers impact ACP documentation rates. To describe patient-reported barriers to ACP among older adults and the association between barriers and ACP documentation. We used baseline data from 1241 English and Spanish-speaking patients enrolled in two trials at two safety-net San Francisco hospitals. We used validated questionnaires to ask participants about ACP barriers using a list of patient, family/friend, and clinician/system-level barriers and an open-ended question, analyzed using content analysis. We conducted chart review for prior ACP documentation. We used Chi-square/Wilcoxon rank-sum tests and linear/logistic regression to assess associations between ACP barriers and demographic characteristics/ACP documentation. Participant mean age was 65+7.4 years; they were 74% racial/ethnic minority groups, 36% Spanish-speaking, and 36% with limited health literacy. 26 barriers were identified (15 patient, 4 family/friend, 7 clinician/system-level), and 91% reported ≥1 ACP barrier (mean: 5.6±4.0). The most common barriers were: (patient-level) discomfort thinking about ACP (60%), wanting to leave health decisions to “God” (44%); (family/friend-level) not wanting to burden friends/family (33%), assuming friends/family already knew their preferences (31%); (clinician/system-level) assuming doctors already knew their preferences (41%) and mistrust (37%). ACP barriers were more common among racial/ethnic minorities vs. non-minorities (76% vs. 53%), Spanish- vs. English-speakers (39% vs. 6%), and those with fair-to-poor vs. good-to-excellent health (48% vs. 34%) or limited vs. adequate health literacy (39% vs. 9%) (p<0.001 for all). Participants who reported barriers were less likely to have ACP documentation (adjusted OR = 0.64, 95% CI [0.42, 0.98]). English- and Spanish-speaking older adults reported 26 unique barriers to ACP, with higher barriers among vulnerable populations, and barriers were associated with lower ACP documentation.