Advance Care Planning Documentation Completeness and End-of-Life Care: Trends and Associations Using HRS 2010-2022 Data

BackgroundAdvance care planning documentation allows individuals to communicate preferences for medical care and designate surrogate decision-makers. It is unknown if comprehensive documentation confers additional benefits.ObjectivesThis study examined additive associations between comprehensive advance care planning (ACP) documentation and end-of-life care (EOL) outcomes among older adults in the United States.Setting/SubjectsData from the Health and Retirement Study exit interviews (2010-2022) indicated ACP documentation status, based on proxy-reported completion of a living will (LW) and/or durable power of attorney (DPOA) for 5622 decedents representing 23.2 million individuals.MeasurementDocumentation was operationalized as a binary variable (any document, no document) and an ordinal variable (no documentation, one document, two documents). EOL outcomes included binary indicators of intensive care unit use in the last two years of life, use of life-sustaining treatments, hospice utilization prior to death, and location of death (out-of-hospital, hospital).ResultsAbout 42.7% decedents had two documents and 28.9% had none, documentation increased substantially around 2014. Compared with no documentation, having any documentation was associated with lower likelihood of life-sustaining treatment (aRR = 0.85, 95% CI: 0.74-0.98) and higher likelihood of hospice utilization (aRR = 1.43, 95% CI: 1.28-1.60) and out-of-hospital death (aRR = 1.11, 95% CI: 1.06-1.18), but not ICU use. Having two documents showed similar patterns. Associations were stronger among decedents with expected death and attenuated among those with unexpected death.ConclusionsACP is associated with less aggressive EOL care and greater hospice use, although the incremental benefits of having both documents are modest.