Advance Care Planning Among the Oldest Old

Published In: Journal of Palliative Medicine, v. 11, no. 2, Mar. 1, 2008, p. 152-157

Posted on RAND.org on December 31, 2007

by Pauline Wu, Karl Lorenz, Joshua Chodosh

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OBJECTIVES: To describe end-of-life advance care planning among the oldest-old (those = 85 years) and to identify patient characteristics and healthcare utilization patterns associated with likelihood of care planning documentation. DESIGN: Medical charts were abstracted for evidence of advance care planning documentation (including surrogate for health care decisions) and linked to patient demographic, clinical, and health utilization characteristics. SETTING: Veterans Affairs Greater Los Angeles Healthcare System (VA GLAHS). PARTICIPANTS: All Veterans (n = 175) aged = 85 who died between September 1999 and October 2000 and used services at the VA GLAHS in the last year of life. Measurements: The association of patient demographic, clinical, and health care utilization characteristics with documentation of advance care planning and surrogates was modeled using multivariate logistic regression. RESULTS: Among veterans (mean age at death, 89.4 plus or minus 3.8 years), 50 of 149 (34%) electronic available records had documented care preferences whereas 68 (46%) had documentation of surrogates. Considering demographic, clinical, and service use characteristics, only age (adjusted odds ratio [AOR]: 1.1 per year; 95% confidence interval [CI]: 1.0-1.2) and outpatient visits (AOR: 1.6 per quartile of general and geriatric medicine visit frequency; 95% CI: 1.1-2.3) were associated with advance directive completion. A multivariable regression model using the same predictors to predict documentation of surrogates found similar associations with total outpatient visits (AOR: 1.5; 95% CI: 1.0-2.0) and general and geriatric medicine utilization. (AOR: 1.4; 95% CI: 1.0-2.0). CONCLUSION: Even in a health care system known for high-quality chronic illness care, documentation of advance care planning and selected proxies for health care decisions at the end of life was infrequent. Outpatient primary care and geriatric providers' visits were more frequent among those who had documented advance care planning, suggesting that involvement of these practitioners may improve end-of-life care.

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