Going It Alone: Advance Directive Discordance in Older Married Couples

Abstract

Contrary to expectations of joint decision-making, a substantial minority of older married couples report only one spouse possessing an advance directive. Using Health and Retirement Study data, the authors examined advance directive discordance among heterosexual married couples in which at least one spouse had completed an advance directive. It was predicted that spouses who differed in age, self-rated health, or race/ethnicity would be more apt to adopt individualistic as opposed to relational motivational stances, resulting in higher odds of nonmatching advance directive status. Heterogamy did not account for discordance, but couples in which one or both spouses attended some college were more likely to report advance directive concordance. In contrast, couples in which one or both spouses were non-White were more likely to display advance directive discordance. Study results raise concerns about the effectiveness and reach of advance care planning promotion efforts among low-education and non-White older married adults.

“Till Death Do Us Part”, Dying Matters, Beyond the Individual: Advance Care Planning Patterns Among Older Couples

“…For married couples, the influence of spouses over each other may play an important role in shaping individual behavior and decisions to engage in formal and informal ACP. Only a small number of studies have examined ACP engagement using information obtained from both spouses (see Koss, 2017; Koss & Jensen, 2020). Given the extensive evidence of concordance in lifestyle and health behaviors and outcomes in married couples through the lens of “linked lives” that shape an individual’s life as indicated by life course scholars (Drewelies et al, 2018; Elder, 1994), it is critical to understand patterns of ACP engagement among older couples, using Latent Class Analysis (LCA) based on the reports from both spouses.…”

“…In one recent qualitative study which interviews 31 older veterans and their surrogates, the majority of participants’ surrogates were their spouses (Fried et al, 2019). Regarding issues which arise at the end of life, the ongoing process of joint-decision making over time could help reduce the level of distress or conflict within the family when it has to make end-of-life care decisions (Koss & Jensen, 2020).…”

“…Another strength of this couple-centered approach based on the reports from matched spouses in a nationally representative survey of older Americans worth underscoring is that this helps identify heterogeneity in the level of both formal and informal ACP engagement between couples. Previous studies using information from both spouses (Koss, 2017; Koss & Jensen, 2020) helped us predict ACP patterns in older couples. First, we expect to observe concordant patters of ACP engagement among older couples, with either a high or low level of engagement from both spouses.…”

“…Although there have been no studies to date examining ACP patterns of older couples using LCA, key demographic, socioeconomic, health, and psychological characteristics are known to be associated with an individual’s and spouse’s engagement with ACP in late life (Boerner et al, 2013; Carr & Luth, 2017; Koss & Jensen, 2020). Gender was reported to affect ACP engagement with women tending to have informal conversations only and being less likely to complete formal documentation about their wishes than men (Boerner et al, 2013).…”

“…A high level of educational attainment is associated with a greater level of ACP engagement (Boerner et al, 2013). Spousal health status including cognitive function of each partner and couple have been significantly associated with ACP behaviors (Koss & Jensen, 2020; Lu et al, in press).…”