Advance Care Planning in the Marital Context: Dyadic Analyses of Advance Directive Completion by Older Married Adults

TitleAdvance Care Planning in the Marital Context: Dyadic Analyses of Advance Directive Completion by Older Married Adults
Publication TypeThesis
Year of Publication2016
AuthorsKoss, CS
Academic DepartmentGerontology
Number of Pages170
UniversityUniversity of Kansas
CityLawrence, KS
Thesis TypeDissertation
KeywordsAdvance directions, Marriage

Advance directive completion is associated with higher quality care at the end of life and increased odds of receiving hospice care and of dying at home. Researchers seeking to understand why some older adults complete advance directives while others do not tend to treat the decision as an individual choice. This individualistic approach fails to account for the interdependent nature of many health decisions made by married persons. I developed a relational model of end-of-life planning adapted from the transtheoretical model of behavioral change (TTM) to more accurately represent advance directive completion by married older adults To evaluate this relational model, I investigated advance directive completion by older married adults as a dyadic process through two interrelated studies. First, with quantitative couple data from the Health and Retirement Study, I examined the relationships between husbands’ and wives’ advance directive completion and each spouse’s age, education, health status, prior hospitalization or outpatient surgery, and regular health care provider using the Actor-Partner Interdependence Model. These variables have been found to be associated with higher odds of advance directive completion in previous studies, but this is the first study to test whether these predictors also exert spousal effects. I found that personal and spousal age and education were positively associated with advance directive completion. Those whose spouses were in poorer health were less likely to have advance directives. Men’s hospitalization or outpatient surgery, but not women’s, was related to an increased probability of having an advance directive for both themselves and their spouses. Women who had a regular source of health care were more likely to have advance directives, but whether a man had a regular health care provider did not affect the likelihood of advance directive completion for either spouse. Taken as a whole, these findings support the proposition underlying the relational model that advance directive completion is associated with both personal and spousal attributes and encounters with health care providers. Second, I interviewed eight married adults (four couples) who had engaged in end-of-life planning including completing advance directives. Through these interviews, I was able to assess whether participants’ accounts of the events leading up to their end-of-life planning corresponded to the decisional stages described in the proposed relational model. I also observed to what extent they presented their motivations and decisions as independent of or interdependent with their spouses’ planning. Advance directive completion was just one part of a broader end-of-life planning process. Participants’ described a gradual process of growing awareness of and interest in end-of-life planning, obstacles that had to be overcome, and triggering events that prompted concrete steps toward completion of advance directives. Many of the factors influencing participants’ progress up to and through end-of-life planning were interpersonal, such as spouses’ health and the illnesses and deaths of parents and parents-in-law. Progressive movement toward end-of-life planning by husbands and wives was also frequently mutually influenced. Although participants’ descriptions were substantially consistent with the relational model I initially developed, I made several adjustments in light of the interview data. In combination, these two studies support the proposition that end-of-life planning by older married adults is an interdependent process shaped by both personal and spousal factors. These influences were present at individual, interpersonal, and organizational context levels. Future research into why older adults complete advance directives should account for the dyadic and contextual nature of these decisions when made by married adults, as should public education efforts and interventions promoting end-of-life planning.

Citation Key9288