Durable Power Of Attorney Research Articles

Missed Opportunities for use of Advanced Care Planning and Palliative Care in Open Aortic Surgery

Major vascular surgery, including open aortic procedures, is associated with having a 30-day mortality rate greater than 6% and a perioperative complication rate greater than 50%. Published literature suggests that patients undergoing high-risk procedures benefit from having a care plan in place to not only maximize quality of life but also to ensure medical interventions align with care goals. Currently, there is a paucity of published data on the prevalence of goals of care conversations, advance care planning documentation, and palliative care evaluations in patients undergoing high-risk vascular operations. A retrospective chart review of all patients who underwent open aortic surgery at a tertiary care academic medical center from July 2014 to March 2023 was performed. Patient demographics, comorbidities, type and timing of advanced care planning (ACP), palliative care evaluations, and clinical outcomes during the periprocedural period were recorded. For patients who died during the study period, the use of palliative care prior to death were noted. Patients who received ACP or palliative care were compared with those who did not. The cohort consisted of 192 patients who underwent major open aortic surgery. The mean age was 63 years (SD 12.3) and the majority of patients were male (73.4%) and white (64.1%). Thirty-nine (20.6%) operations were classified as emergent. At the time of their operation, 16.7% (n=32) of patients had an ACP document on file. Of the 38 documents on file, most were durable power of attorney (DPOA) (86.8%) documents while a smaller percentage were physician orders for life-sustaining treatment (POLST) (13.2%). There were no patients with Do Not Resuscitate and/or Intubate (DNR/DNI), living will, or organ/tissue donation orders noted in their chart prior to surgery. One percent (n=2) of patients had a palliative evaluation prior to their operation. During the perioperative period, an additional 2 (1%) of patients had advanced care planning documentation and 7 (3.7%) of patients underwent palliative care evaluation. Fifteen percent of patients (n=28) died during the perioperative period and an additional 21 patients died by the end of the study period for a total mortality of 25.2% in the study population. Among patients that died during the perioperative period, 28.6% (n=8 out of 28) received palliative care. Overall, 28.6% of all study patients that died (n=14 out of 49) received a palliative care evaluation prior to or during their terminal hospitalization. Patients who had ACP documents or who received palliative care consultations prior to surgery were older (p=0.01), more likely to be on Medicare or Medicaid (p=0.004), and more likely to have a history of solid organ malignancy (p=0.03). The median interval between surgery and receiving palliative care was 20 (IQR 3-71) days. The median interval between palliative care and death was 5 (IQR 2-13) days. Patients who utilized ACP or PC were more likely to die at home (p=0.05). Despite a high mortality and morbidity rate, ACP documentation is poor for patients undergoing major open aortic surgery. Palliative care interventions tend to be performed closer to the end of life, suggesting a missed opportunity to define goals of care.

Factors affecting advance care planning in older adults with cancer

IntroductionAdvance care planning (ACP) has been widely endorsed and recommended for its many potential benefits, including improved end-of-life (EOL) care, enhanced satisfaction with care, and reduced anxiety and depression. However, little is known about the ACP completion rates and factors affecting ACP among older adults with cancer. This study's purpose was to examine biological, psychological, and social factors affecting ACP in this population. Materials and MethodsData from the 2002 to 2016 waves of exit interviews from the national longitudinal Health and Retirement Study were analyzed. The sample included 1088 decedents, aged 55 and over, who had a diagnosis of cancer. The exit interviews were completed by a proxy respondent (usually the next of kin of the decedents). ACP outcomes included: having EOL care discussion, durable power of attorney (DPOA), and advance directives (ADs). Multiple logistic regression models were conducted to examine the relationships between predictor variables and each of the three ACP outcome variables. ResultsApproximately 65% of the sample had ever discussed EOL care, 61.9% had an assigned DPOA, and 54.1% had ADs. Regression results showed that higher age, Black race, high school and above education, being widowed/never married, higher multimorbidity, and more limitations in activities of daily living and instrumental activities of daily living were significantly associated with the three ACP variables. Surprisingly, Black race was associated with higher odds of ever discussing EOL care and having ADs; high school and above education was associated with lower odds of all three ACP components. DiscussionThe majority of participants in this study had discussed EOL care, had an assigned DPOA, and had ADs. However, most participants were White/Caucasian and had completed high school education. Future research that includes more diverse and minoritized participants is needed. Also, the contrasting association of Black race and higher educational status with ACP outcomes warrant further exploration in future studies.

Advance care planning among older cancer survivors in the United States.

91 Background: The goal of advance care planning (ACP) is to ensure that end-of-life (EOL) care is consistent with patient wishes and preferences. The ACP is particularly relevant to older adults with cancer due to their high risk of mortality. However, it remains unclear whether older cancer survivors have a higher rate of ACP engagement than general older adults. Methods: We used data from the National Health and Aging Trends Study (NHATS) Round 8, a nationally representative study of adults aged ³65. This cross-sectional analysis included 4,666 participants (1,568 cancer survivors), representing 33.93 million older Americans in 2018. The ACP was defined as having any of the three self-reported elements of ACP: EOL discussion, durable power of attorney (DPOA), or living will/advance directive. Cancer survivors were identified by self-reported cancer in Round 8 or prior rounds. Covariates were self-reported, including age, sex, race, marital status, education level, income, number of comorbidities, number of limitations in activities of daily living (ADL) and probable/possible dementia. We used logistic regressions to examine the association of cancer diagnosis and ACP engagement, adjusting for covariates and complex survey design and weights. Results: Older cancer survivors reported a higher rate of ACP engagement (80.10% vs 73.39), EOL discussion (66.94% vs 60.92%), DPOA (58.56% vs 51.02%) and living will/advance directive (63.34% vs 52.81%), compared to older adults without cancer. However, in adjusted logistic models, there was not significant difference between the two groups in ACP engagement (adjusted OR=1.12, 95% CI: 0.93, 1.36, P=0.22), EOL discussion (adjusted OR=1.08, 95% CI: 0.91, 1.29, P=0.37), DPOA (adjusted OR=1.07, 95% CI: 0.90, 1.28, P= 0.42) or living will/advance directive (adjusted OR=1.20, 95% CI: 1.00, 1.45, P=0.05). The oldest old (>80 years), women, White people, single/not married, with higher education, income, comorbidities and ADL limitations were more likely to engage in ACP (all P<0.01). The associations were similar across models that explored the individual elements of ACP. Conclusions: Despite the high mortality risk, older cancer survivors are not more likely to engage in ACP than the general older adults. About 20% of US older cancer survivors have not engaged in any form of ACP. Hospital, clinic and community strategies to introduce and encourage ACP among older cancer survivors are needed, especially for those minority populations.

Utilizing an innovative digital collaboration tool to impact shared decision making, health equity and trust with a focus on advance care planning for patients with metastatic breast cancer.

e24123 Background: Advance care planning (ACP) has been associated with improved quality of life, increased use of hospice and palliative care, and less use of extreme treatments close to death. These conversations often do not occur and documentation rates of ACP in oncology patients have been as low as 10%, with rates of documentation increasing between 30-40% in intervention studies. The present study aimed to examine the effectiveness of an online Advance Care Appointment Companion (ACAC) collaboration tool to improve communication and elevate trust between MBC patients and their oncologist and increase completion rates of ACP documents. Methods: Data were collected from 48 patients with mean age of 66.9 years (SD = 6.97) with MBC during their medical oncology appointments (Time 1) and three months later (Time 2) at the Koontz Center for Advanced Breast Cancer. At Time 1, patients were enrolled on the ACAC platform and then completed questions in the clinic or at home about completion status of a healthcare directive and durable power of attorney (DPOA) for healthcare, comfort in discussing ACP with their care team and loved ones, and goals of care at end of life. A summary of these responses with a provider prompt script was securely sent to the oncologist prior to each appointment and used to discuss ACP over the three-month study period. Descriptive statistics, t-tests, McNemar-Bowker and McNemar’s tests were conducted to examine changes in rates of ACP document completion, patient reported levels of comfort in discussing ACP, and quality of life preferences. Results: The study included a diverse sample of female MBC patients including 79% White, 19% Black/African American, 2% Mixed Race; 6% less than a high school degree, 17% high school or GED, 19% some college, and 58% associate’s degree or above. Results showed a significant increase in completion of a healthcare directive (Time 1 = 10.4%, Time 2 = 37.5%, p < .01) and DPOA (Time 1 = 31.5%, Time 2 = 56.3%, p < .01) and improved comfort discussing ACP with their care team (p < .01) and loved ones (p < .01) from baseline to follow-up. Significantly more patients reported that they would not want CPR (p < .05) at follow-up and all of these patients had reported that they were unsure at baseline. On average, ACP conversations during medical appointment took 5 minutes to discuss. Conclusions: Results show that the ACAC is an inclusive solution which provides equitable access to patients. This tool facilitates enhanced patient provider communication and assists patients with MBC in finalizing decisions regarding their goals of care, leading to increased completion and proper submission of ACP documentation. Future research should examine how the ACAC can decrease financial toxicity, utilize internal resources, and address social determinants of health.

Abstract P5-15-03: The effectiveness of an advance care appointment companion to increase completion of advance care planning among patients with metastatic breast cancer

Abstract Previous research has demonstrated that patients express a desire to discuss advance care planning (ACP). ACP has been associated with numerous positive outcomes including improved patient satisfaction, improved quality of life in terminal illness, and better psychological outcomes. Additionally, ACP has been related to peace of mind that wishes will be followed, less hospital re-admissions, and less use of extreme treatments close to death. Furthermore, it has been linked to increased use of hospice and palliative care and increased concordance between preferred care and the care delivered. However, despite the documented benefit of ACP, these conversations often do not occur due to discomfort with the topic or are communicated inadequately. Documentation rates of ACP in oncology patients have been as low as 10%, with rates of documentation increasing between 30-40% in intervention studies. Specific to women with metastatic breast cancer (MBC), one study found that 66% had written advance directives, but providers were only aware of these in 14% of the cases. Thus, the present study aimed to examine the effectiveness of an online Advance Care Appointment Companion (ACAC) decision-support tool to improve ACP communication between MBC patients and their oncologist and increase completion rates of ACP documents. Data were collected from 68 patients with MBC during their medical oncology appointments (Time 1) and three months later (Time 2) at the Koontz Center for Advanced Breast Cancer. At their Time 1 clinic visit, patients were introduced to and enrolled on the ACAC platform and then completed questions in the clinic or at home about completion status of a healthcare directive and durable power of attorney (DPOA) for healthcare, comfort in discussing ACP with their care team and loved ones, goals of care at end of life, and discussion topics about ACP for upcoming visits. A summary of these responses with a provider prompt script was securely sent to the oncologist prior to each subsequent appointment over the three-month study period. The oncologist used this summary and scripting to help navigate ACP conversations during each appointment. Descriptive statistics and McNemar’s test were conducted to examine changes in rates of ACP document completion and patient reported levels of comfort in discussing ACP. Majority of the sample was female (n=68, 100%), white (n=57, 84%), married (n=36, 53%), with a mean age of 64 years. At baseline, 41% of patients reported having a completed healthcare directive and 49% reported having a completed DPOA for healthcare, but only 12% had a healthcare directive and 24% had a DPOA in their electronic medical record (EMR). To-date, 35% (n=24) have a healthcare directive and 47% (n=32) have a notarized DPOA in their EMR; McNemar’s test showed a significant increase in the proportion of patients who completed ACP documents at Time 2 (p< .001). At baseline, 74% of patients reported feeling comfortable discussing ACP with their care team and 69% reported feeling comfortable discussing ACP with their loved ones. Of note, 35% reported that they were unsure if they would want artificial nutrition, 37% reported they were unsure if they would want dialysis, and 37% reported that they were unsure if they would want resuscitation in the event that their heart stops. On average, ACP conversations during medical appointments took 5 minutes to discuss. Preliminary results suggest that the ACAC is an effective tool to facilitate discussion about ACP, resulting in significantly increased completed ACP documents in patient’s medical records. Assessment of patient-reported outcomes on comfort with discussing ACP and goals of care at Time 2 is ongoing. Results also revealed the potential for this tool to help foster communication about the intricacies of ACP as a large portion of patients reported that they were unsure about decisions that need to be made about end of life care. Citation Format: Kadie M Harry, Cathy E Mitchell, Loic Nijiakin, Arabella Sykes, Timothy J Pluard. The effectiveness of an advance care appointment companion to increase completion of advance care planning among patients with metastatic breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-15-03.

Findings on Loneliness, Telehealth, and Advance Care Planning From the National Poll on Healthy Aging

The University of Michigan National Poll on Healthy Aging (NPHA) taps into the perspectives of older adults to inform health care policy and practice using a nationally representative sample of more than 2,000 adults age 50-80. Questions about lack of companionship and feelings of loneliness were tracked over three time points; 34% expressed feelings of loneliness in October 2018, 41% in June 2020, and 37% in January 2021. The NPHA also found that use of telehealth increased from 4% in May 2019 to 30% in June 2020 to 43% in January 2021. Finally, the NPHA found that 37% have completed both medical durable power of attorney and advance directive with 7% completing at least one of these documents in the first three months of the COVID-19 pandemic. These poll results can be used to inform actions by coalitions and organizations to advance state and federal policy.

POSTER ABSTRACTS 1- 48: 2021 ASCIP Hybrid Educational Conference & Expo

Context: This is a case of a 71-year-old male who presented with sudden onset tetraplegia after a mechanical ground level fall. He was diagnosed with a traumatic C3 AIS B spinal cord injury (SCI) and neurogenic shock requiring vasopressors and intubation. He underwent C3-C5 surgical decompression and stabilization. His course was complicated by cardiac arrest, aspiration pneumonia, alcoholic pancreatitis, and failure to wean off vasopressors. Findings: The patient was alert and intermittently cognitively intact, but his communication was limited by intubation. The healthcare team discussed his likely prognosis including long-term artificial ventilation, tube feeding, and severe tetraplegia. Under COVID-19 restrictions, the patient's wife, his durable power of attorney, and son had limited encounters with the patient. Initially, she wanted to pursue tracheostomy so the patient may participate in goals of care discussions. However, the family recalled his preference to not be on life support. The decision was made to withdraw care and he passed away on hospital day 11. Conclusion/Clinical Relevance: This case highlights the ethical dilemma of withdrawing care in the acute phase of a severe traumatic SCI. While undergoing intensive care, many factors interfere with decision making including the patient's acute medical status, altered cognition, communication limitation, and the family's physical distance and emotional state. Lastly, the patient and his family may not have had sufficient time to process the given information and understand that a meaningful life is possible with a severe disability. Informed decision making includes not only clear and thorough information but also time to adjust.

The Right to Choose

The Right to Choose

Examining Associations Between Legal Frameworks for Medical Planning and Intensity of End-of-Life Care

This study aims to understand the correlation between the legal framework around planning for medical treatment and the intensity of care received at the end of life. Advance directives (AD) allow an individual to legally document their wishes for medical treatment and end-of-life care, and durable powers of attorney (DPOA) allow them to identify an individual to make medical decisions on their behalf in the event they are no longer able. These laws vary greatly across time, place, and in their complexity. We estimated fixed effects model, which controls for time-invariant and state-specific factors affecting end-of-life care. Our primary outcome variable is the number of inpatient hospital days during the last six months of life, sourced from the Dartmouth Atlas Project. Our explanatory variables are hand-collected state-level legal statutes including whether the state (a) has default surrogate laws, (b) recognizes the ability to create a DPOA and/or AD, (c) permits oral directives, (d) authorizes a combined AD/DPOA, and (e) provides an official registry for ADs. Preliminary findings show recognizing DPOA and AD are negatively correlated with our outcome variable (-2.6 days; Std err 0.272) as are having default surrogate laws (-0.36 days; std err 0.157). However, allowing oral directives had an opposite effect (-.46 days; std err 0.157). Neither authorized combined AD/DPOAs nor AD registries resulted with significant correlations. These findings indicate that the existence of a basic framework such as default surrogate laws and a law governing ADs are key policy features correlated with reduced intensity in end-of-life care.

Marital Status and Gender Differences in End-of-Life Planning

Less than half of older adults make formal preparations to control difficult life transitions, yet planning can mitigate negative outcomes that accompany changes. To better understand multiple forms of end-of-life planning behaviors and the effect of demographic characteristics, we use data from the Understanding America Study (N=1812; aged 60+). We explored gender and marital differences in whether respondents created a will, living will, or declared a durable power of attorney for health care (DPOAHC), and who was chosen as DPOAHC (i.e., spouse, child, other relative). T-tests determined no significant gender differences in declaring a DPOAHC, creating a will, or living will. An analysis of variance (F=13.422, df=3, p<0.001) found married respondents more likely to declare a DPOAHC than separated/divorced (p<0.001) and never married respondents (p=0.002). Divorced respondents were less likely to declare a DPOAHC compared to widowed respondents (p<0.001) and widowed respondents were more likely compared to never married respondents (p=0.001). Additional analyses found the same pattern in who created a will or living will. A follow-up analysis of variance found no gender differences within marital status categories (i.e., married men versus married women). Overall, respondents who were never married were less likely to have prepared any forms of end-of-life planning. These results highlight the importance of having close relationships on the level of preparedness for end-of-life planning. Additional implications include increasing awareness about end-of-life planning for more vulnerable audiences. Future analyses will integrate findings regarding financial DPOAHC and examine other socio-demographic characteristics, such as education and race.

The Relationship Between Subjective Age, Health Status, and Advance Care Planning

Current data show that how old a person feels, or subjective age (SA), may be associated with improved well-being and functioning, less cognitive impairment, and longer life. Yet, the relationship between SA and advance care planning (ACP) has yet to be examined. This is all the more important when determining the role SA has in end-of-life decision-making. Using data from the Health and Retirement Study (Wave 13, 2016), this study aimed to examine whether SA is associated with having a living will (LW), having a LW with life-limiting care, and having assigned a durable power of attorney. The sample included 3,165 participants 51+ years of age (mean age = 65.67; SD = 11.79). Analyses were conducted assessing the predictive value identified social, behavioral, and health factors have for ACP. Results from binomial logistic regression analyses indicated that participants who endorsed feeling older than their chronological age were similarly likely to have engaged in ACP as those who felt younger. As demonstrated previously, older chronological age was significantly associated with higher utilization of ACP (ps < .05). Those with cancer and women were significantly more likely to have a LW (ps <.05). The present study did not find evidence to support a significant relationship between SA and ACP. Lower overall engagement with ACP and treatment for specific conditions, such as cancer, may be more influential in determining who utilizes ACP. Future research should explore how SA may serve as a protective factor and/or a psychological mechanism that influences engagement in ACP.

Do Perceptions of Own and Spouse Survival Affect Advance Care Planning?

COVID-19 has intensified the need for advance care planning (ACP), or formal preparations for end-of-life care, prior to the time such decisions are required. We propose that older adults’ perceived chances of survival, and one’s perceptions of whether they will outlive their spouse may be powerful motivators of ACP. Using data from the Wisconsin Longitudinal Study (WLS, n=4908, M age = 65), we examine the extent to which: (a) one’s perceived 10- and 20-year survival and (b) projections of dying before, after, or at the same time as one’s spouse affect three aspects of ACP (living will, durable power of attorney for health care designations (DPAHC), and discussions). Multivariate analyses are adjusted for health, demographics, socioeconomic characteristics, and death anxiety. In the full sample, women who perceived a high likelihood of 20-year survival were less likely (OR=.604, p < .05) whereas their male counterparts were more likely (OR = 1.4, p <.01) to name a DPAHC (relative to those who perceived a medium likelihood of survival). Among married persons only (n=3860), people who perceive that they will pre-decease their spouse are 1.5 times as likely to name their spouse as DPAHC (vs. no DPAHC), but are no more likely to name a different person to the role (relative to those who perceive that they and spouse will die at the same time). Practitioner and family conversations about older patients’ projected survival and how it shapes decision making are especially important as COVID-19 may require rapid decisions about end-of-life treatments.

The Association Between Hearing Loss and Completion of Advance Care Planning Among Older Adults

Background: Ensuring access to quality end-of-life (EOL) care for all older adults is emerging public health concern. Hearing loss (HL) is the third most common chronic disease affecting older adults and a major impediment to access healthcare services. However, little is known about the impact of HL on advance care planning for older adults. Method: A sample of 1,862 older adults (≥65 years) was drawn from the National Health and Aging Trends Study (NHATS). HL was determined by self-report and advance care planning was measured by asking if an individual completed living wills or the Durable Power of Attorney for Health Care (DPAHC). Covariates included age, gender, race, marital status, education, religion, nativity, depression, region, facility status, regular doctor availability, Medicaid, hospitalization, cognition, perceived health status and a presence of chronic disease. Results: Descriptive statistics revealed that nearly 67% of older adults with HL completed the DPAHC, and the majority of them (71%) also had living wills. Multivariable logistic regression analyses showed that HL was significantly associated with completion of DPAHC and living wills, after controlling for a list of covariates (OR=0.50, p<0.05). Conclusions: The findings show HL is a significant predictor of completion of any type of advance directives. Facilitating effective communication in advance care planning for older adults with HL is needed. Healthcare provider should make health information accessible to them to get quality EOL care.

Racial and Ethnic Disparities at End of Life Among Persons With Alzheimer’s Disease and Related Dementias

End-of-life (EOL) care for persons with Alzheimer’s disease and related dementias (ADRD) is heterogeneous and, often, inconsistent with patients’ priorities. While differences in physician-patient communication or the health care decision-making process likely contribute to disparities in EOL care, little is known about the relationships between race, advance care planning (ACP), and quality of care among persons with ADRD. The aim of this study was to (1) characterize trends in both ACP and EOL treatment intensity in persons with ADRD and (2) test whether racial differences in ACP mediate disparities in EOL care. We analyzed a population-based cohort of older adults with cognitive impairment or dementia who participated in the Health and Retirement Study (HRS) and died between 2000 and 2014 (n = 5,316). While participation in ACP among persons with ADRD increased from 2000 to 2014 (66% to 83%, P < 0.05), models stratified by race showed that differences in participation rates across white and nonwhite persons with ADRD persisted over the sample period. Racial disparities in the location of death, a proxy for the intensity of EOL care, narrowed from 2000 to 2014. However, next-of-kin surrogates of nonwhite persons with ADRD were much more likely to report the decedent received “all care possible…in order to prolong life”. Assignment of a durable power of attorney was found to influence location of death, while both creation of a living will and participation in discussions about EOL care preferences were found to influence the likelihood that decedents received all possible life-prolonging treatments.

The Mediation Role of Socioeconomic Status on Racial and Ethnic Differences in Advance Care Planning

Background. Most research on EOL care planning has focused on racial/ethnic differences in completing advanced directives (AD) rather than the pathways of the disparities. Therefore, this study aims to examine the mediating role of education and income in racial/ethnic differences in EOL care planning. Methods. A secondary data analysis of Health and Retirements Study (HRS) 2004-2014 wave was used. The sample included 6,518 participants ((≥ 65 years old). The independent variable measured the respondents’ race and ethnicity and the dependent variable measured the completion rate of living wills or the Durable Power of Attorney of Health Care (DPAHC). Covariates included gender, age, marital status, religion, place f birth, educational attainment, income, cognitive function, limitations in physical functioning, geriatric syndromes, and the number of progressive chronic disease. Results. The hierarchical logistic regression analysis showed that race/ethnicity was a significant predictor of completing AD (p≤0.001). Mediation analysis, Karlson, Home, and Breen (KHB), revealed that both education and income explained 14.4% of racial/ethnic differences in completion of living wills for non-Hispanic Blacks and 17.6% for Hispanics. Similarly, education and income accounted for 17.6% of racial/ethnic disparities in completion of DPAHC for non-Hispanic Blacks and 20.9% for Hispanics. In particular, education had stronger mediating effect on the outcome variables than income. Discussion. The findings suggest the importance of targeted educational interventions for people of color with lower SES to raise their awareness of benefits of advance care planning and increase their access to higher quality of EOL care.

Mom's Money is Missing: Bank Records Analysis in a Fraud Examination Case

ABSTRACT Bank records analysis is a vital component of many forensic accounting and fraud examination engagements. This case provides students with a hands-on opportunity to conduct a fraud examination based upon a detailed review of bank records. The context of this case is an elderly client who has appointed her son as her durable power of attorney. Unfortunately, he violates his fiduciary duty and misappropriates money from his mother. The students' assignment is to trace the missing money through numerous bank accounts and prepare a report for the local county attorney who will prosecute the case. Students will learn how to trace money through multiple bank accounts, prepare a succinct report for the prosecutor, cope with a large quantity of source documents, and manage a relatively unstructured task.

Low Rates of Advance Care Planning (ACP) Discussions Despite Readiness to Engage in ACP Among Liver Transplant Candidates.

Patients with end-stage liver disease awaiting liver transplantation (LT) are seriously ill and experience fluctuating periods of clinical decompensation. Discussion of a patient's advance care planning (ACP) wishes early in their dynamic disease course is critical to providing value-aligned care while awaiting LT. We aimed to evaluate current ACP documentation and assess readiness to engage in ACP in this population. We conducted a retrospective study of adults undergoing LT evaluation from January 2017 to June 2017 and assessed characteristics associated with documentation using logistic regression. We then administered a survey to LT candidates from March 2018 to May 2018 to determine self-reported readiness to engage in ACP (range 1 = not at all ready to 5 = very ready). Among 170 LT candidates, median (interquartile range) age was 58 (53-65), 65% were men, MELDNa was 15 (11-21), and Child-Pugh A/B/C were 33/38/29%. Nine percent reported completing ACP prior to LT evaluation, but 0% had legal ACP forms or end-of-life wishes documented in the medical record. A durable power of attorney (DPOA) was discussed with 10%. In univariable analysis, white race (OR 4.16, p = 0.03) and female sex (OR 3.06, p = 0.04) were associated with ACP documentation, but Child-Pugh score and MELDNa were not. Of the 41 LT candidates who completed the ACP survey, 93% were ready to appoint a DPOA and 85% were ready to discuss end-of-life care. There is a paucity of ACP documentation and identification of DPOA among LT candidates, despite patients reporting readiness to complete ACP and appoint a DPOA. These results reveal an opportunity for tools to facilitate discussions around ACP between clinicians, patients, and their caregivers.

Understanding End-of-Life Preferences: Predicting Life-Prolonging Treatment Preferences Among Community-Dwelling Older Americans

ObjectivesTo determine how demographic, socioeconomic, health, and psychosocial factors predict preferences to accept life-prolonging treatments (LPTs) at the end of life (EOL). MethodsThis is a retrospective cohort study of a nationally representative sample of community-dwelling older Americans (N = 1648). Acceptance of LPT was defined as wanting to receive all LPTs in the hypothetical event of severe disability or severe chronic pain at the EOL. Participants with a durable power of attorney, living will, or who discussed EOL with family were determined to have expressed their EOL preferences. The primary analysis used survey-weighted logistic regression to measure the association between older adult characteristics and acceptance of LPT. Secondarily, the associations between LPT preferences and health outcomes were measured using regression models. ResultsApproximately 31% of older adults would accept LPT. Nonwhite race/ethnicity (odds ratio [OR] 0.54; 95% CI 0.41, 0.70; white vs. nonwhite), self-realization (OR 1.34; 95% CI 1.01, 1.79), attendance of religious services (OR 1.44; 95% CI 1.07, 1.94), and expression of preferences (OR 0.54; 95% CI 0.40, 0.72) were associated with acceptance of LPT. LPT preferences were not independently associated with mortality or disability. ConclusionsApproximately one-third of older Americans would accept LPT in the setting of severe disability or severe chronic pain at the EOL. Adults who discussed their EOL preferences were more likely to reject LPT. Conversely, minorities were more likely to accept LPT. Sociodemographics, physical capacity, and health status were poor predictors of acceptance of LPT. A better understanding of the complexities of LPT preferences is important to ensuring patient-centered care.

Advance Care Planning: Social Isolation Matters.

Social isolation is a risk factor for poor health that influences the well-being older adults. We compare advance care planning (ACP) engagement of older adults who were severely socially isolated, socially isolated, and not socially isolated. Cross-sectional analysis of the 2012 National Health and Aging Trends Study (NHATS). United States of America. A total of 2015 older adults (aged ≥65 years) randomly selected from a representative sample of community-dwelling Medicare beneficiaries to participate in an ACP module as part of an annual in-person interview. We classified participants in three groups: severely socially isolated, socially isolated, or not socially isolated. ACP refers to three (yes/no) questions regarding whether a participant had a: (1) prior discussion about care preferences in the case of serious illness (EOL Discussion); (2) durable power of attorney (DPOA); and (3) advance directive (AD). We performed logistic regression analyses to examine the association between social isolation and ACP. Approximately 23% of older adults were either severely socially isolated or socially isolated. Older adults who experienced social isolation were less likely to engage in ACP than those who were not socially isolated. In adjusted analysis, older adults who were socially isolated had lower odds of having an EOL discussion (adjusted odds ratio [AOR] = 0.65; 95% confidence interval [CI] = 0.49-0.87) or having a DPOA (AOR = 0.71; 95% CI = 0.53-0.96) compared to those who were not socially isolated. Social isolation is associated with lower engagement in ACP. Clinicians should identify older adults who are at risk for or experience social isolation as they may benefit from targeted ACP efforts. J Am Geriatr Soc 68:841-846, 2020.

WHAT MATTERS FOR COMPLETION OF ADVANCE DIRECTIVES AMONG AMERICAN OLDER ADULTS?

Background: Most previous studies consider advance directives as one single outcome, which conceals possible variations of individuals’ decisions on two different advance directives documents–living will (LW) and durable power of attorney for healthcare (PA). To advance the knowledge on advance planning among older adults in the US, this study examined how health status and education are associated with completions of LW and PA and whether such associations vary by age and race. Methods: Data are from the 2016 wave of Health and Retirement Study. Health status was indicated by chronic condition and ADL and IADL functional limitations. Logistic regression model was used to examine how the completions of LW and PA are associated with health and education variables respectively. Interaction terms were created to test the moderating effects of race and age. Results: The analysis results show that older adults with higher IADL functional limitation and more education were more likely to complete completing PA or LW. Being white and higher age will increase the probability for an older adult to complete PA, whereas the older adults with heart problem were more likely to complete LW. The association between IADL/ADL and PA was stronger in white than other racial groups, and the association between IADL and LW was stronger in young-old than the oldest-old. Conclusion: The findings highlight the importance of examining the completions of two advance directive documents respectively and indicate the necessity of developing distinct and concrete strategies to promote the completions of PA and LW.