Advance care planning and the quality of end-of-life care in older adults.

TitleAdvance care planning and the quality of end-of-life care in older adults.
Publication TypeJournal Article
Year of Publication2013
AuthorsBischoff, KE, Sudore, RL, Miao, Y, W Boscardin, J, Smith, AK
JournalJ Am Geriatr Soc
Date Published2013 Feb
ISSN Number1532-5415
KeywordsAdaptation, Psychological, Advance care planning, Aged, 80 and over, Female, Humans, Male, Quality of Life, Terminal Care, United States

OBJECTIVES: To determine whether advance care planning influences quality of end-of-life care.

DESIGN: In this observational cohort study, Medicare data and survey data from the Health and Retirement Study (HRS) were combined to determine whether advance care planning was associated with quality metrics.

SETTING: The nationally representative HRS.

PARTICIPANTS: Four thousand three hundred ninety-nine decedent subjects (mean age 82.6 at death, 55% women).

MEASUREMENTS: Advance care planning (ACP) was defined as having an advance directive (AD), durable power of attorney (DPOA) or having discussed preferences for end-of-life care with a next of kin. Outcomes included previously reported quality metrics observed during the last month of life (rates of hospital admission, in-hospital death, >14 days in the hospital, intensive care unit admission, >1 emergency department visit, hospice admission, and length of hospice ≤ 3 days).

RESULTS: Seventy-six percent of subjects engaged in ACP. Ninety-two percent of ADs stated a preference to prioritize comfort. After adjustment, subjects who engaged in ACP were less likely to die in a hospital (adjusted relative risk (aRR) = 0.87, 95% confidence interval (CI) = 0.80-0.94), more likely to be enrolled in hospice (aRR = 1.68, 95% CI = 1.43-1.97), and less likely to receive hospice for 3 days or less before death (aRR = 0.88, 95% CI = 0.85-0.91). Having an AD, a DPOA or an ACP discussion were each independently associated with a significant increase in hospice use (P < .01 for all).

CONCLUSION: ACP was associated with improved quality of care at the end of life, including less in-hospital death and increased use of hospice. Having an AD, assigning a DPOA and conducting ACP discussions are all important elements of ACP.


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Endnote Keywords

Advance care planning/End of life/quality of care/hospice/Advance directives/Durable power of attorney

Endnote ID


Alternate JournalJ Am Geriatr Soc
Citation Key7821
PubMed ID23350921
PubMed Central IDPMC3760679
Grant ListK23 AG040772 / AG / NIA NIH HHS / United States
KL2 RR024130 / RR / NCRR NIH HHS / United States