Advance directive completion by elderly Americans: a decade of change

Objectives: To describe trends in advance directive (AD) completion from 2000 to 2010 and to explore the relationship between AD and hospitalization and hospital death at the end of life.

Design: Retrospective cohort study.

Setting: Health and Retirement Study (HRS).

Participants: HRS participants who died between 2000 and 2010 and were aged 60 and older at death (N = 6,122).

Measurements: Trends over time in rates of AD completion, hospitalization before death, and death in hospital are described. The association between trends in AD completion and hospital death was then assessed by comparing nested, multivariable logistic regression models predicting the odds of hospital death over time with and without adjusting for AD status and sociodemographic characteristics. The complex sampling design was accounted for in all analyses.

Results: The proportion of decedents with an AD increased from 47% in 2000 to 72% in 2010. At the same time, the proportion of decedents with at least one hospitalization in the last 2 years of life increased from 52% to 71%, and the proportion dying in the hospital decreased from 45% to 35%. After adjusting for confounding by sociodemographic characteristics, the trend in declining hospital death over the decade was negligibly associated with the greater use of ADs.

Conclusion: There has been a significant increase in rates of AD completion over the last decade, but this trend has had little effect upon hospitalization and hospital death, suggesting that AD completion is unlikely to stem hospitalization before death.