“We expected to see that older adults in worse health more
frequently discussed of end-of-life plans and preferences,” said
Krista Lyn Harrison, a geriatrics researcher, Division of
Geriatrics, School of Medicine, University of California, San
Francisco. “Instead, we saw either no difference or less frequent
discussions in these populations,” she said.
“In the case of older adults with dementia, they or their proxies
reported discussing advance care planning less frequently than those
without dementia,” Harrison told Reuters Health by email.
The researchers used data from the long-term National Health and
Aging Trends Study of community-dwelling Medicare beneficiaries aged
65 years and older who responded to the 2015 main survey and a
supplemental module in 2012.
Participants answered questions about whether or not they had
discussed with anyone what medical treatment they desired if they
became seriously ill in the future, whether they had legal
arrangements for a proxy to make decisions about medical care and
whether they had written instructions about desired medical
treatment in the form of an advance directive.
They also reported their age, sex, race, education level, income
level, self-rated health, number of chronic health conditions,
disability in activities of daily living and if they had a dementia
About 2,000 Medicare beneficiaries completed the surveys and 1,156
reported having had an end of life discussion, 997 had a legal proxy
for health decisions, and 1,027 had an advance directive.
Almost 30 percent of people had none of the three advance-care
elements, while almost 40 percent had all three, according to the
results in JAMA Internal Medicine, October 31.
Men, African Americans, Latinos, those with lower levels of
educational attainment and lower annual income were less likely than
others to have two or more of the three advance care planning
elements. Older Spanish-speaking Latinos were the least likely to
have taken these steps, with 19 percent saying they had had an end
of life discussion, 20 percent had a legal proxy and 17 percent had
an advance directive. In comparison, rates for non-Hispanic whites
in the same categories were 66 percent, 54 percent and 59 percent,
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It’s not clear what drives these disparities, Harrison said.
“Our worry is that these differences may occur because clinicians
are not proactively engaging older adults and their loved ones in
culturally-appropriate discussions about their end-of-life plans and
preferences until too late,” she said. “In the case of dementia,
often dementia is not recognized as a terminal illness and thus
discussions are not begun early enough,” she said.
“Race-based differences might be caused by cultural differences in
willingness to engage in these discussions, or differences in access
to clinicians who are able to have these discussions in the language
and culture most comfortable to the older adult and their loved
ones,” Harrison said.
JAMA Intern Med 2016.
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