Advance Care Planning and the Quality of End-of-Life Care in Older Adults

Abstract

Objectives

To determine whether advance care planning influences quality of end-of-life care.

Design

In this observational cohort study, Medicare data and survey data from the Health and Retirement Study (HRS) were combined to determine whether advance care planning was associated with quality metrics.

Setting

The nationally representative HRS.

Participants

Four thousand three hundred ninety-nine decedent subjects (mean age 82.6 at death, 55% women).

Measurements

Advance care planning (ACP) was defined as having an advance directive (AD), durable power of attorney (DPOA) or having discussed preferences for end-of-life care with a next of kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice ≤3 days).

Results

Seventy-six percent of subjects engaged in ACP. Ninety-two percent of ADs stated a preference to prioritize comfort. After adjustment, subjects who engaged in ACP were less likely to die in a hospital (adjusted relative risk (aRR) = 0.87, 95% confidence interval (CI) = 0.80–0.94), more likely to be enrolled in hospice (aRR = 1.68, 95% CI = 1.43–1.97), and less likely to receive hospice for 3 days or less before death (aRR = 0.88, 95% CI = 0.85–0.91). Having an AD, a DPOA or an ACP discussion were each independently associated with a significant increase in hospice use (P < .01 for all).

Conclusion

ACP was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an AD, assigning a DPOA and conducting ACP discussions are all important elements of ACP.