Factors related to the execution/non-execution of advance directives by community-dwelling adults with decisional capacity

Abstract

Available evidence does not indicate an increase in the rate of execution of advance directives (ADs) following implementation of the Patient Self-Determination Act (PSDA) on 12/1/91. Although the community is perceived as a more conducive context than a healthcare institution for the execution of ADs, the rate of AD execution also has remained static among community-dwelling adults following implementation of the PSDA. Little is known about the factors related to the execution or non-execution of ADs by community-dwelling adults. This study described the enabling, experiential, socio-spiritual, and demographic characteristics of community-dwelling adults who had executed ADs, i. e., terminal care documents and/or durable powers of attorney for health care, and of community-dwelling adults who had not executed ADs; investigated relationships among the characteristics and the execution or non-execution of ADs; and examined differences between executors and non-executors of ADs related to the characteristics. Data were collected by mail from a random sample of 530 residents of one Northeastern state, using a self-administered, 68-item researcher-constructed questionnaire. The response rate was 51% (n=210) after three mailings with 18.1% (n=38) having executed an advance directive (AD). The AD proportion was consistent with those reported in earlier studies of community-dwelling adults that have been conducted since the implementation of the PSDA. Major study variables included dimensions of personal autonomy and self-determination, concern for family, death anxiety, religiosity, familiarity with ADs, AD education, personal experience with the terminal illnesses or critical injuries of family members and/or friends, physician-initiated AD discussions, and concern about an executed AD having a negative impact on one's care. Significant differences between executors and non-executors of ADs on the study variables included executors being more familiar with ADs, F(1,205) = 65.69, p < .0001, reporting more AD education, Z = -5.82, p < .0001 having more experiences with the terminal illnesses or critical injuries of family members and/or friends, F(1,201) = 8.33, p = .0043, engaging in physician-initiated AD discussions more often, Z = -4.75, p < .0001, expressing greater concern about having an executed AD negatively impact one's care, F(1,202) = 5.20, p = .0236, having a higher degree of religiosity, F(1,180) = 6.41, p = .0122, and being older, F(1,207) = 24.06, p < .0001, than non-executors. Path analysis of variables with significant correlations indicated that physician-initiated discussions about ADs, familiarity with ADs, AD education, concern about the negative impact of an executed AD on one's care, concern for family, religiosity, age, and health status were effective predictors (p <= .05) of the execution of an AD, explaining 30% of the variance (R2adj). The findings suggest that being informed about ADs is fundamental to their subsequent execution. Information-building about ADs among autonomous individuals appears to be a process that is constituted by multiple factors, including familiarity with ADs, physician-initiated AD discussions, AD education, and experiences with the terminal illnesses or critical injuries of family members and/or friends. Furthermore, ongoing AD discussions between healthcare professionals and AD executors seem warranted to clarify patients' understanding of previously executed ADs.