Examining Age Inequalities in Operationalized Components of Advance Care Planning: Truncation of the ACP Process With Age.

Abstract

Opportunities for patients to receive unnecessary, costly, and potentially harmful care near the end of life abound. Advance care planning (ACP) can help to make this vulnerable period better for patients, caregivers, and providers. The objective of this study was to determine whether older age predicted the presence of certain forms of retrievable ACP documentation in the electronic health record (EHR) in a large sample of hospice-referred patients. This was a retrospective analysis of medical-record data on 3595 patients referred to hospice between January 1, 2013 and December 31, 2015. EHR documentation of an ACP note in the problem list, presence of a scanned advance directive, and the presence of a verified do-not-resuscitate order were the outcome measures. Logistic regression was used to assess the effect of age, education, race, gender, cancer diagnosis, dementia diagnosis, palliative encounter, and death on the outcome variables. Our results suggest that when we control for prognosis, patients over age 70 years may experience gaps in ACP communication. We found that as patients age, the odds of having documentation of a conversation (odds ratio [OR] = 0.56; P < 0.001) or scanned advance directive decreased (OR = 0.63; P < 0.001), while the odds of having a verified do-not-resuscitate order increased (OR = 1.42; P < 0.001). The results of this study may imply some degree of unilateral and physician-driven decision making for end-of-life care among older adults. Collaborative efforts between an interdisciplinary medical team should focus on developing policies to address this potential disparity between younger and older adults at the end of life.