It is well-established that few U.S. adults, even those who are older and terminally ill, have completed advance directives for end-of-life care.1 However, not as much is known about the advance care planning of healthcare providers.
“Doctors, lawyers, social workers, and other professionals can play an important role in motivating their patients and clients to do advance care planning,” notes Deborah Carr, PhD, professor and chair of sociology at Boston University.
Yet these professionals do not consistently initiate advance care planning conversations with patients.2 In some cases, it is because of clinicians’ own discomfort with end of life. Researchers wanted to know if those most integrally involved with end-of-life decisions have finalized their own directives. If healthcare providers manage their own plans, they can share firsthand insights. “They will be in a better position to inform, guide, and support their patients. It will make them a more effective, trusted, and knowledgeable resource,” Carr says.
Carr and colleagues analyzed data from the Health and Retirement Study (HRS) and Wisconsin Longitudinal Study (7,668 and 5,464 subjects, respectively).3 As expected, frontline healthcare workers were more likely to create advance care directives compared to other professionals. However, researchers were surprised that workers in the “social and health services” category (social workers, chaplains, and others who work with dying patients and their families) created directives at a lower rate.
For instance, in the HRS sample, 78% of doctors had drawn up a living will vs. just 41% of social workers. The proportion naming a durable power of attorney for healthcare was 64% and 32%, respectively. Non-professional workers (e.g., factory workers, food service workers, and other manual labor) recorded the lowest rates of advance care planning for the occupational groups that were studied.
“This is an important finding. As we have learned from the COVID-19 pandemic, people working in physically grueling jobs, often with high levels of interaction with the public, are at particular risk of illness and premature death,” Carr explains.
Advance care planning is especially important for economically disadvantaged populations, although they may be the least likely to have the means or support to do so. “Healthcare providers, social workers, and other professionals who work with lower-income populations or those working in physically risky jobs should take extra care to encourage their advance care planning,” Carr says.
Handling this work up front can prevent the need for some ethics consults. If the patient’s treatment preferences have been made clear, there is less chance of a conflict at the end of life. “Bioethicists also should be encouraged to do their own advance care planning so that they have firsthand knowledge of the kinds of struggles their hospital’s patients may be managing,” Carr offers.
A common end-of-life conflict is family disagreements about the types of treatments the patients should receive. “This can cause lingering tensions among siblings or between widows [or widowers] and children after their loved one dies,” Carr says.
Bioethicists who have discussed their own treatment preferences with family members are better equipped to help hospital patients do the same. “The exercise of completing one’s own advance directive, and understanding what each potential treatment option entails, may also help them to understand the potential risks and benefits their patients are considering,” Carr says.
- Yadav KN, Gabler NB, Cooney E, et al. Approximately one in three U.S. adults completes any type of advance directive for end-of-life care. Health Aff (Millwood) 2017;36:1244-1251.
- Belanger E, Loomer L, Teno JM, et al. Early utilization patterns of the new Medicare procedure codes for advance care planning. JAMA Intern Med 2019;179:829-830.
- Carr D, Kalousova L, Lin K, Burgard S. Occupational differences in advance care planning: Are medical professionals more likely to plan? Soc Sci Med 2021;272:113730.