Did a patient complete an advance directive in his or her last months of life? If so, there is a greater chance of choosing aggressive care, found a recent study.1

“We undertook this study to better understand the relationship between timing of advance directive development and patient preference for aggressive care,” says Susan Enguidanos, PhD, MPH, the study’s lead author. Enguidanos is associate professor of gerontology at University of Southern California in Los Angeles.

Nearly three-quarters of advance directives were completed a year or more before death. Younger age, being a racial/ethnic minority, having lower education, a diagnosis of cancer or lung disease, and an expected death were associated with completing an advance directive within the three months before death.

“Our findings support recommendations to begin advance care planning discussions early in the disease trajectory,” says Enguidanos.

Minorities, those with lower education, expected death, and timing of advance directive completion were associated with electing aggressive care. “These factors may reflect poor discussions around care decisions, perhaps conducted during a medical crisis,” says Enguidanos.

Mechanisms to promote patient-physician discussion on end-of-life care and subsequent documentation of this discussion through an advance directive are needed, says Enguidanos: “This may increase patient knowledge and better reflect patient values in their decision-making — and, ultimately, in the care they receive at end of life.”

In another recent study, researchers found that 46% of decedents had completed an advance directive. Blacks had 75% lower odds of completing an advance directive than whites, and Hispanics had 70% lower odds than whites. Of blacks completing an advance directive, 24% elected prolonged care, compared with 13% of Hispanics and 3% of whites.2

Based on previous studies, the researchers expected lower rates of advance directive completion among minority groups. However, they didn’t expect the gap between whites and minorities to be so wide. “We were surprised at the size of the difference in odds between whites and African-Americans and Hispanics,” says Enguidanos.

It’s unclear to what extent this gap is an indication of fewer advance care planning conversations between physicians and minority patients. This is a potential ethical issue, says Enguidanos: “Although outside of the scope of this study, these findings point to the need for further investigation along these lines.”


1. Enguidanos S, Ailshire J. Timing of advance directive completion and relationship to care preferences. J Pain Symptom Manage 2017; 53(1):49-56.

2. Portanova J, Ailshire J, Perez C, et al. Ethnic differences in advance directive completion and care preferences: What has changed in a decade? J Am Geriatr Soc 2017; 65(6):1352-1357.


• Susan Enguidanos, PhD, MPH, Associate Professor of Gerontology, University of Southern California, Los Angeles. Phone: (213) 740-9822. Email: enguidan@usc.edu.