Differences in advance care planning among frail elders in long-term care settings

Nursing home (NH) residents represent a population for whom advance care planning is especially important due to the prevalence of cognitive impairment and frequency of death of this population. Yet there have been no comparisons of NH residents to similar frail elders receiving long-term care (LTC) services in other settings such as assisted living facilities (ALF) and home and community based services (H&CBS). As part of a NIA funded study to examine the natural history of changes in health related quality of life, we examined advanced care planning among elders newly admitted or enrolled in LTC settings. Baseline data on 272 subjects (NHs, n=53; ALFs, n=98; H&CBS, n=121) revealed that 60% (164/272) have a living will and/or durable power of attorney for health care when they entered LTC. Variables used in building a multiple logistic regression model included age, cognitive status, education, race, sex, and LTC setting. Results indicate that NH subjects and ALF subjects were more likely to have a written advance directive than H&CBS subjects (NH: OR=1.6, p=0.11; ALF: OR=6.3, p<0.001; H&CBS reference group). Male residents (OR= 2.15, p=0.02) and subjects with at least a high school education (OR=2.85, p=0.001) were also more likely to have a written advance directive. Elders receiving H&CBS may have less access to advance directives due to not being in a formal LTC setting. These data fill a gap in the literature on advance care planning among community-dwelling elders. Future research studies to assess advance care planning preferences among this population are needed.