Differences in Informal and Formal Advance Care Planning Use by Race/Ethnicity Among U.S. Older Adults

Outcomes 1. Identify key racial and ethnic disparities in various advance care planning strategies 2. Identify opportunities for advance care planning among a racially or ethnically diverse population Original Research Background Capturing patients’ healthcare treatment preferences is critical for guiding end-of-life care. Goals-of-care conversations (i.e., informal advance care planning [ACP]) may better capture these preferences than advance directives (i.e., formal ACP), particularly among historically marginalized racial and ethnic groups. Research Objectives To compare the use of informal versus formal ACP strategies by race and ethnicity among U.S. older adults. Methods We used 2012-2018 Health and Retirement Study data to assess ACP strategies among 14,148 older (≥65 years) respondents. ACP was categorized as (1) no ACP, (2) informal ACP only, (3) formal ACP only, and (4) both informal and formal ACP. Multinomial logistic regression models estimated relationships between self-identified race or ethnicity and ACP strategy, controlling for sociodemographic and health status characteristics. Adjusted risk ratios with delta standard errors were computed. Results Overall, 18.9% of the sample reported no ACP, 15.4% informal ACP only, 7.4% formal ACP only, and 58.3% both ACP strategies. In adjusted results (adjusted relative risk [95% CI]), non-Hispanic Black and Hispanic respondents were 1.73 [1.56, 1.93] and 1.61 [1.39, 1.87] times more likely, respectively, to report no ACP than non-Hispanic White respondents. Compared to non-Hispanic White respondents, Hispanic respondents were 1.50 [1.28, 1.76] times more likely to report informal ACP only, and non-Hispanic Black respondents were 1.70 [1.41, 2.05] times more likely to report formal ACP only. Non-Hispanic Black and Hispanic respondents were 0.75 [0.71, 0.79] and 0.76 [0.70, 0.82] times as likely, respectively, to report using both ACP strategies than non-Hispanic White respondents. Conclusion and Implications Older individuals of racial and ethnic minority were less likely to use a combination of informal and formal ACP strategies and more likely to be without any ACP. Lower use of various ACP strategies among these populations may contribute to poor end-of-life outcomes and should be addressed by clinicians, researchers, and policymakers.