Disparities in Advance Directive Completion and Life-Sustaining Treatment Preferences in Older Adults

Alaa Albashayreh; Nahid Zeinali; Yuya Hagiwara; Stephanie Gilbertson-White

doi:10.1016/j.jpainsymman.2025.02.451

1. Identify the demographic and clinical factors associated with disparities in advance directive completion and recognize the association between advance directive completion and the life-sustaining treatment preference in older adults with chronic conditions. 2. Discuss the use of novel methods like natural language processing (NLP) to extract patient-centered information including life-sustaining treatment preferences from clinical narratives and assess their implications for palliative care research. This study highlights disparities in advance directive completion and their association with life-sustaining treatment preferences among older adults with chronic conditions. It demonstrates how natural language processing systems like Care-BERT can extract treatment preferences from clinical narratives to generate real-world evidence at scale. Engaging older adults with chronic conditions in completing advance directives (AD) is essential to ensuring their treatment preferences, particularly regarding life-sustaining treatments, are respected. Despite the increasing recognition of AD importance, completion rates remain low, and disparities persist across different demographic groups. To examine disparities in AD completion and assess the association between AD completion and life-sustaining treatment choices among older adults with chronic conditions. This retrospective study analyzed electronic health records (EHR) from 14,303 older adults with chronic conditions treated in a Midwestern US healthcare system. Logistic regression models were employed to assess the impact of demographic and clinical factors on AD completion and the choice of life-sustaining treatments. To extract treatment preferences from EHR narratives, we used Care-BERT, a natural language processing (NLP) model specifically tailored for this study. The mean age of the sample was 78.5±6.04 years. AD completion was less likely among older individuals (OR = 0.935; 95% CI: 0.930, 0.940), but more likely among those with a cancer diagnosis (OR = 1.521; 95% CI: 1.391, 1.664). Non-White individuals had significantly lower odds of completing an AD compared to White individuals (OR = 0.646; 95% CI: 0.538, 0.775). AD completion was associated with a higher likelihood of choosing life-sustaining treatments (OR = 1.822; 95% CI: 1.567, 2.117). Additionally, non-White individuals (OR = 2.283; 95% CI: 1.349, 3.861) and non-English speakers (OR = 3.492; 95% CI: 1.049, 11.624) were more likely to choose life-sustaining treatments. These findings highlight disparities in AD completion and life-sustaining treatment preferences among older adults. By leveraging NLP tools like Care-BERT, EHR narratives can yield key insights into treatment preferences. Future efforts should focus on developing interventions that promote equitable access to advance care planning and enhance patient-centered care. - Jimenez, G., Tan, W. S., Virk, A. K., Low, C. K., Car, J., & Ho, A. H. Y. (2018). Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons. Journal of Pain and Symptom Management, 56(3), 436-459.e425. https://doi.org/10.1016/j.jpainsymman.2018.05.016 - McMahan, R. D., Tellez, I., & Sudore, R. L. (2021). Deconstructing the Complexities of Advance Care Planning What Do We Know and Where Do We Go? A Scoping Review. Journal of the American Geriatrics Society, 69(1), 234-244. https://doi.org/10.1111/jgs.16801 - Morin, L., & Onwuteaka-Philipsen, B. D. (2021). The promise of big data for palliative and end-of-life care research. Palliative Medicine, 35(9), 1638-1640. https://doi.org/10.1177/02692163211048307

Disparities in Advance Directive Completion and Life-Sustaining Treatment Preferences in Older Adults

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