End-of-Life Care

Advance care plans of nursing home residents vary by age, race/ethnicity, and income

Advance care planning documents ensure that nursing home residents' wishes will be carried out when they are no longer capable of making decisions about their care. Advance care plans vary substantially by nursing home residents' age, race/ethnicity, and income, according to a new study. Racial and ethnic minorities were less likely to have advance care plans than whites. Also, nursing home residents who had less daily contact with friends or relatives and lower household income were less likely to have do-not-resuscitate (DNR) orders, feeding/medication/other treatment (FMT) restrictions, and living wills in place.

It is not clear whether these disparities are due to inadequate education about advance care plans or differing attitudes and beliefs, notes Aram Dobalian, Ph.D., J.D., of the University of California, Los Angeles. Dr. Dobalian used the Nursing Home Component of the 1996 Medical Expenditure Panel Survey, a nationally representative sample of 815 nursing homes and 5,899 residents, to examine documentation of advance care plans among residents. Overall, about 53 percent of the population (3,105 residents) had at least 1 advance care plan. DNR orders were less common among blacks and Latinos than whites. DNR orders were more prevalent among residents 75 years and older and those with severe cognitive impairment, dementia, emphysema, cancer, and longer nursing home stays.

Latinos were less likely to have FMT restrictions than blacks and whites. Living wills were more common among residents aged 75 years and older and those with psychiatric/mood disorders and heart disease, but less prevalent among blacks. Residents with less social engagement and household incomes below 400 percent of the Federal poverty level were less likely to have living wills. Residents with Medicaid as their largest payer were less likely to have an advance care plan than those with Medicare or other payment mechanisms. The study was supported by the Agency for Healthcare Research and Quality (HS00046).

More details are in "Advance care planning documents in nursing facilities: Results from a nationally representative survey," by Dr. Dobalian, in the September/October 2006 Archives of Gerontology and Geriatrics 43, pp. 193-212.

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