Family Structure, Experiences with End-of-Life Decision Making, and Who Asked About Advance Directives Impacts Advance Directive Completion Rates

Background: Advance directives are an important but underutilized resource. Reasons for this underutilization need to be determined. Objective: We investigated factors associated with completion of advance directives among inpatients. Design: We conducted prospective, structured interviews on family structure, health care, disease, and end-of-life experiences. We compared those with completed advance directives and those without. Setting/Subjects: We interviewed 130 inpatients in an urban university hospital. Measurements: We used bivariate analysis and logistic regression to identify characteristics of patients with living wills and health care proxies versus patients without them. Results: Twenty-one percent of patients had a living will and 35% had a health care proxy. Patients with completed living wills were older (p <= 0.0046), had more comorbidities (p=0.018), were widowed (p=0.02), and were more often admitted with chronic disease (p=0.009) compared to those without living wills. Patients with health care proxies were older (p<0.001), had religious affiliations (p=0.04), more children (p=0.03), and more often widowed (p <= 0.001) than those without health care proxies. Patients were 10.8 times (95% confidence interval [CI] 4.59-25.3), 46.5 times (95% CI 15.1-139.4), and 68.6 times (95% CI 13.0-361.3) more likely to complete a living will when asked by medical staff, legal staff, or family and friends, respectively, than those not asked. Patients with health care proxies were 1.68 times (95% CI 0.81-3.47), 4.34 times (95% CI 1.50-12.6), and 18.0 times (95% CI 2.03-158.8) more likely to have been asked by the same groups. Patients with experience in end-of-life decision-making were 2.54 times more likely to possess a living will (95%CI 1.01-6.42) and 3.53 times more likely to possess a health care proxy (95% CI 1.51-8.25) than those without experiences. Conclusions: Having been asked about advance directives by medical staff, legal staff, or family and friends increases the likelihood that patients will possess an advance directive. Those with prior experience with end-of-life decision-making are more likely to possess an advance directive. Family structure and health care utilization also impacts possession of advance directives.