Catheryn Koss

Race Differences in Advance Directive Completion: The Narrowing Gap Between White and African American Older Adults

Objective: Rates of advance directive completion have increased over the past decade, but significant race differences remain. This study examined how overall increases in advance directive completion have affected disparities between White and African American older adults. Method: Data were taken from the Health and Retirement Study (HRS). Using logistic regression models, the odds of having an advance directive among a sample of older African Americans and Whites who died between 2001 and 2012 were compared (N = 5,832). Results: Odds for African Americans were 16% of the odds for Whites, p < .001, 95% confidence interval (CI) = [0.11, 0.23]. There were no significant interactions between race and year of death before 2010. During 2010-2012, the increase in the odds for African Americans was greater than for Whites, odds ratio (OR) = 1.95, p = .02, 95% CI = [1.14, 3.35]. Discussion: Although race disparities remain, the gap between Whites and African Americans has begun to narrow.

Beyond the Individual: The Interdependence of Advance Directive Completion by Older Married Adults

To determine how individual and spousal demographic and health factors are associated with advance directive (AD) completion by married older adults.

Where There’s a Will: The Link Between Estate Planning and Disparities in Advance Care Planning by White and Black Older Adults:

Data from the Health and Retirement Study (n = 6,946) were used to test whether differences in estate planning accounted for disparities in advance care planning between White and Black older adults. White participants were more likely to have advance directives after controlling for demographic, health, and financial variables. When estate planning was also controlled, the odds of having an advance directive were equal for White and Black participants. In contrast, Whites remained more likely to discuss end-of-life preferences after controlling for demographic, health, financial, and estate planning variables. White participants were almost four times as likely to have wills or trusts. Wealth, income, and home ownership were predictive of estate planning. Financial disparities contributed to lower rates of estate planning which in turn explained in large part why Black older adults were less likely to have advance directives but did not account for race disparities in advance care discussion.

Does Religiosity Account for Lower Rates of Advance Care Planning by Older African Americans

Objectives Advance care planning (ACP) is associated with higher quality care at the end of life and increased odds of receiving hospice care and of dying at home. Older African Americans are less likely to complete advance directives (ADs) or discuss life-sustaining treatment preferences. This study examined whether religiosity accounts for race disparities. Method Analyses were conducted with Health and Retirement Study data (1,180 African Americans, 5,681 Whites). Two forms of ACP were regressed on race, five measures of religiosity, and demographic, health, and health care covariates. Results Whites were twice as likely to engage in ACP. Including religiosity predictors did not close these gaps. Frequency of service attendance was positively associated with AD completion for both White and African American participants. Relationships between religious affiliation and advance care discussion varied by race. For White participants only, more frequent prayer was associated with higher odds of advance care discussion. Discussion Although religiosity is often proposed as a reason for low rates of ACP among African Americans, religiosity measures did not explain race differences. Distinct aspects of religiosity were associated with ACP both negatively and positively, and these relationships varied by type of ACP and by race.

Encounters With Health-Care Providers and Advance Directive Completion by Older Adults

Background: The Patient Self-Determination Act (PSDA) requires hospitals, home health agencies, nursing homes, and hospice providers to offer new patients information about advance directives. There is little evidence regarding whether encounters with these health-care providers prompt advance directive completion by patients. Objective: To examine whether encounters with various types of health-care providers were associated with higher odds of completing advance directives by older patients. Method: Logistic regression using longitudinal data from the 2012 and 2014 waves of the Health and Retirement Study. Participants were 3752 US adults aged 65 and older who reported not possessing advance directives in 2012. Advance directive was defined as a living will and/or durable power of attorney for health care. Four binary variables measured whether participants had spent at least 1 night in a hospital, underwent outpatient surgery, received home health or hospice care, or spent at least one night in a nursing home between 2012 and 2014. Results: Older adults who received hospital, nursing home, or home health/hospice care were more likely to complete advance directives. Outpatient surgery was not associated with advance directive completion. Conclusions: Older adults with no advance directive in 2012 who encountered health-care providers covered by the PSDA were more likely to have advance directives by 2014. The exception was outpatient surgery which is frequently provided in freestanding surgery centers not subject to PSDA mandates. It may be time to consider amending the PSDA to cover freestanding surgery centers.

A Question of Trust: Does Mistrust or Perceived Discrimination Account for Race Disparities in Advance Directive Completion?

Abstract Background and Objectives Advance directive completion is associated with end-of-life quality indicators such as dying at home and receiving hospice care. Black older adults are less likely to complete advance directives than their white counterparts. The underlying reasons for these race disparities are not well understood. Research Design and Methods In two related studies, data from the Health and Retirement Study were used to examine whether mistrust in health care providers and/or perceived discrimination accounted for lower rates of advance directive completion by black older adults in the United States. Odds of advance directive completion were modeled using logistic regression and multiple measures of trust in health care providers and both medical and nonmedical perceived discriminatory treatment. Results In Study 1 (n = 699), controlling for medical mistrust did not reduce the gap between black and white participants’ odds of possessing advance directives. In Study 2 (n = 2,736), higher percentages of black participants reported experiencing medical and nonmedical discriminatory treatment. However, none of the measures of discrimination accounted for black participants’ lower odds of possessing advance directives. Discussion and Implications These results call into question the common assertion that mistrust in medical providers or the health care system contributes to lower rates of advance care planning by black older adults. Future research should examine the potential relationships between advance directive completion and other dimensions of discrimination.