(The pdf for the issue in which this article appears is available for download: Bifocal, Vol. 38, Issue 6.)
Approximately 40% of older adults in the United States require surrogate decision making at the end of life because they become unable to formulate or articulate instructions about their health care. When no information about a person’s preferences is available, the general legal presumption is that the individual would choose to receive all medical treatment necessary to sustain life. However, if a person adequately communicates his or her preferences about life-sustaining treatment in advance while still competent, this presumption no longer applies and the patient’s expressed wishes should guide medical decisions. The ongoing process of reflecting on and informing loved ones and health care providers about how future medical decisions should be made in the event of incapacity is called advance care planning (ACP).
The process often results in a legal document called an advance directive, the format of which varies but usually consists of two parts: a living will and a durable power of attorney for health care. The living will allows individuals to state what medical treatments they would or would not wish to receive under certain conditions such as a persistent vegetative state or irreversible and severe cognitive impairment. The durable power of attorney for health care is used to nominate one or more health care proxies to act on one’s behalf in the event of incapacity. Individuals may also communicate their wishes verbally instead of or in conjunction with completing advance directives.
ACP is associated with some important end-of-life quality indicators, including dying at home rather than in a hospital and receiving hospice care before death. Numerous studies have observed that Black older adults are significantly less likely to engage in ACP compared to their White counterparts. This is particularly concerning given the relationship between ACP and end-of-life care. Black elders are less likely to receive hospice or other palliative care at the end of life and are less likely to have their pain effectively managed.
Proposed explanations for relatively low rates of ACP among Black older adults include mistrust of doctors and the health care system, religiosity, reluctance to acknowledge terminal prognosis, greater desire for life-sustaining treatment, lower health literacy, and doubt about the efficacy of ACP. Despite numerous studies testing many of these theories, the underlying mechanisms for race disparities in ACP are still not well understood. One possible contributing factor is disproportionality in estate planning (i.e., the making of a will, trust, or other legal document to dispose of property after death). Having a will is highly predictive of having an advance directive and has been suggested as a possible reason for race disparities.
Using data from the Health and Retirement Study (HRS), the present study tests whether ACP disparities between White and Black older adults can be explained by differences in estate planning. We also examined the relationships between estate planning and demographic, health, financial, and ACP variables. We hypothesized that accumulative financial disadvantages would account for lower rates of estate planning among older Blacks. Estate planning was predicted to explain race disparities in ACP, particularly advance directive completion.
This presentation will be part of the Rapid Fire Plenary on October 27 at 8:30 a.m. in the Pinnacle Grand Ballroom.
Catheryn Koss, J.D., Ph.D., is Assistant Professor of Gerontology at California State University, Sacramento.
These materials are adapted from the following article: Koss, C. S., & Baker, T. A. (2017). “Where There’s a Will: The Link between Estate Planning and Disparities in Advance Care Planning by White and Black Older Adults.” Research on Aging. Advance online publication. doi:10.1177/0164027517697116.
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