Occupational differences in advance care planning: Are medical professionals more likely to plan?

https://doi.org/10.1016/j.socscimed.2021.113730Get rights and content

Highlights

  • Medical professionals are most likely to do and discuss advance care planning (ACP).

  • Non-professionals are least likely to do ACP, a pattern accounted for by education.

  • Medical professionals' own ACP may make them trustworthy advisors to patients.

Abstract

Advance care planning (ACP) helps ensure that treatment preferences are met at the end of life. Medical professionals typically are responsible for facilitating patients' ACP, and may be especially effective in doing so if they have first-hand insights from their own planning. However, no large-scale U.S. studies examine whether persons working on the front lines of health care are more likely than other workers to have done ACP. We contrast the use of three ACP components (living wills, durable power of attorney for health care, and informal discussions) among persons working in medical, legal, social/health support services, other professional, and other non-professional occupations. Data are from the Health and Retirement Study (n = 7668) and Wisconsin Longitudinal Study (n = 5464). Multivariable logistic regression analyses are adjusted for socioeconomic, demographic, health, and psychosocial factors that may confound associations between occupational group and ACP. Medical professionals in both samples are more likely than other professional workers to discuss their own treatment preferences, net of all controls. Medical professionals in the WLS are more likely to execute living wills and DPAHC designations, whereas legal professionals in the HRS are more likely to name a DPAHC. Non-professional workers are significantly less likely to do all three types of planning, although these differences are accounted for by socioeconomic factors. Social and health services professionals are no more likely than other professionals to do ACP. The on-the-job experiences and expertise of medical professionals may motivate them to discuss their own end-of-life preferences, which may render them more trustworthy sources of information for patients and clients. The Affordable Care Act provides reimbursement for medical professionals' end-of-life consultations with Medicare beneficiary patients, yet practitioners uncomfortable with such conversations may fail to initiate them. Programs to increase medical professionals’ own ACP may have the secondary benefit of increasing ACP among their patients.

Introduction

The Coronavirus pandemic has fueled public conversations about “good” and “bad” deaths, where the latter is marked by physical discomfort, difficulty breathing, social isolation, psychological distress, and the receipt of unwanted medical interventions or the lack of treatments one desires (Krikorian et al., 2020; Leland, 2020). Media images of patients dying alone, debates over the rationing of ventilators, and anecdotal reports of front-line medical professionals reckoning with their own premature mortality have intensified calls for widespread advance care planning (Moorman et al., 2020). Advance care planning (ACP) helps to ensure that dying persons who lack decision-making capacity yet have not previously stated their treatment preferences receive end-of-life care that is concordant with their preferences and values (IOM, 2014).

ACP entails executing an advance directive, which comprises a living will and/or a durable power of attorney for health care (DPAHC) designation. A living will is a legal document specifying the treatments a person would like to receive if incapacitated. A DPAHC legally permits a person appointed by the patient to make health care decisions if the patient is incapable of doing so. Patients also are encouraged to discuss their values and treatment preferences with family, caregivers, and professionals who may make decisions for them at the end of life (Carr and Khodyakov, 2007; Carr and Luth, 2017). Despite the importance of ACP, less than half of U.S. adults ages 18 and older, and 50 to 70 percent of persons ages 60 and older have an advance directive (Yadav et al., 2017). Lack of ACP may leave patients vulnerable to care that is discordant with their wishes, and relegates decisions to caregivers who may be not be prepared to make those choices (Silveira et al., 2010).

Medical, legal, and social services professionals often educate patients and encourage their end-of-life preparations (IOM, 2014). However, professionals are most effective in promoting behaviors among their patients and clients when they have performed these behaviors themselves; this first-hand experience makes them more knowledgeable, trustworthy, and persuasive role models (Oberg and Frank, 2009). Conversely, professionals who avoid their own ACP may have knowledge gaps or psychological barriers that inhibit effective end-of-life consultations with their patients and clients (Arnett et al., 2017; Perry Undem, 2016). However, we know of no studies that examine whether persons working in professions most integral to facilitating ACP are especially likely to have done so themselves.

We address this gap in the literature by evaluating: (1) the extent to which older adults working (or who formerly worked) in medical, legal, and social and health support professions; other professional occupations; and other non-professional occupations differ with respect to end-of-life preparations; and (2) the extent to which observed differences persist after adjusting for socioeconomic, demographic, health, and psychosocial correlates of both occupation and ACP. We use data from two large longitudinal studies of older adults, the Health and Retirement Study (HRS) and Wisconsin Longitudinal Study (WLS). Both assessed ACP behaviors in 2011–12 and have collected detailed occupational histories, making them ideally suited for this study.

Section snippets

Occupational differences in advance care planning

Occupations expose workers to specific knowledge, interpersonal encounters, and daily experiences that shape attitudes and behaviors beyond the workplace (Hodson and Sullivan, 2012). We propose that persons who work in occupations with direct or peripheral experience with end-of-life concerns may be especially likely to execute living wills, DPAHC appointments, and discuss their end-of-life treatment preferences. Front-line medical professionals like physicians and nurses are especially likely

Data

Analyses are based on data from the HRS and WLS; both focus on comparable cohorts of older adults, yet the samples differ with respect to education and race/ethnicity. All WLS participants are white Wisconsin high school graduates, whereas the HRS sample is racially and educationally diverse. Both surveys assessed ACP in 2012 and are similar with respect to contextual influences like the high-visibility Terri Schiavo case, which heightened awareness of ACP in the early 2000s (Sudore et al., 2008

Descriptive analysis

Descriptive statistics are presented in Table 1. Rates of ACP in the HRS sample are comparable to those found in other population-based studies of U.S. older adults (IOM, 2014; Yadav et al., 2017); 48 percent have a living will or a DPAHC, and 61 percent discussed their end-of-life plans. Considerably higher percentages of WLS participants executed a living will (69 percent), named a DPAHC (73 percent), or held informal discussions (81 percent), relative to the HRS sample. The WLS sample has a

Discussion and conclusions

We contrasted the ACP behaviors of five occupational groups, taking advantage of two large data sets that include measures of both ACP and occupational histories. Our results make a novel contribution to understanding how work experiences and expertise may shape ACP. Prior studies focused on single occupations only and did not compare occupational groups with direct, partial, or no obvious exposure to end-of-life issues, nor did they explore the extent to which occupational differences reflect

Credit author statement

Deborah Carr: Conceptualization, Data Analysis, Writing – Original draft preparation, Reviewing and Editing; Lucie Kalousova: Conceptualization, Data Analysis, Writing – Reviewing and Editing; Katherine Lin: Conceptualization, Writing- Reviewing and Editing; Sarah Burgard: Conceptualization, Writing – Reviewing and Editing.

Acknowledgements

The National Institute on Aging (NIA) provided funding for the Wisconsin Longitudinal Study (R01AG009775, R01 AG033285), and Americans’ Changing Lives (RO1AG09978, RO1AG018418) data used in this study.

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    K. Link carried out this reserach while a faculty member at Dartmouth College, USA

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