Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults

Abstract

Objectives: To assess engagement in multiple steps of the advance care planning (ACP) process 6 months after exposure to an advance directive. In this study, ACP is conceptualized similarly to the behavior change model.

Design: Descriptive study.

Settings: County general medicine clinic in San Francisco.

Participants: One hundred seventy-three English or Spanish speakers, aged 50 and older (mean 61) given a standard (12th-grade reading level) and an easy-to-read (5th-grade reading level) advance directive.

Measurements: Six months after exposure to two advance directives, self-reported ACP contemplation; discussions with family, friends discussions with clinicians; and documentation were measured. Associations were examined between ACP steps and between subject characteristics ACP engagement.

Results: Most participants (73%) were nonwhite and 31% had less than a high school education. Sixty-one percent contemplated ACP, 56% discussed ACP with family or friends, 22% discussed ACP with clinicians, and 13% documented ACP wishes. Subjects who had discussed ACP with their family or friends were more likely to discuss ACP with their clinicians (36% vs 2%, P<.001) and document ACP wishes (18% vs 4%, P=.009) than those who had not. Latinos and subjects with less than a high school education discussed ACP more often with family or friends (P<.06) and clinicians (P<.03) than other ethnic groups and subjects with more education.

Conclusions: ACP involves distinct steps including contemplation, discussions, and documentation. The ACP paradigm should be broadened to include contemplation and discussions. Promoting discussions with family and friends may be one of the most important targets for ACP interventions, and literacy- and language-appropriate advance directives may help reverse patterns of sociodemographic disparities in ACP.

Figure 1. Conceptual model of the Process of Advance Care Planning*†

* Bolded boxes are the steps of the ACP process described in this study † Conceptual model adapted from Prochaska, et. al. and Pearlman, et. al.

Figure 2. Percentage of participants who completed each step of the advance care planning process, n=147

* These results did not appreciably change after excluding 19 participants who had not seen their doctors in the six months since the advance directive preference study or the 26 participants who had filled out an advance directive prior to the preference study. ^† Data missing for one participant