The Social Stratification of Older Adults’ Preparations for End-of-Life Health Care

Abstract

I use data from the Wisconsin Longitudinal Study (n = 4,971) to evaluate the extent to which socioeconomic status affects three health-related (living will, durable power of attorney for health care, and discussions) and one financial (will) component of end-of-life planning. Net worth is positively associated with all four types of planning, after demographic, health, and psychological characteristics are controlled. Low rates of health-related planning among persons with low or negative assets are largely accounted for by the fact that they are less likely to execute a will, an action that triggers health-related preparations. Rates of health-related planning alone are higher among recently hospitalized persons, whereas financial planning only is more commonly done by homeowners and those with richer assets. The results suggest that economically advantaged persons engage in end-of-life planning as a two-pronged strategy entailing financial and health-related preparations. Implications for health policy, practice, and theory are discussed.

Trends in Engagement in Advance Care Planning Behaviors and the Role of Socioeconomic Status

“…It is possible that individuals from higher income households were more likely to designate a DPAHC because they were prompted to do so by an attorney during estate planning, an activity in which individuals from lower income households may be less likely to engage. 21 In most states, however, the costs associated with ACP-including the designation of a DPAHC-are minimal (eg, cost of notary services). 38 Perhaps if individuals living on fixed incomes were aware that ACP could be accomplished at little to no cost, they would be more likely to legally designate a surrogate decision maker for health care.…”

Understanding End-of-Life Decision-Making Terminology Among African American Older Adults

“…Regardless of prognosis, African American individuals do not prepare for life's end, and are more likely than Caucasian individuals to request life-sustaining treatment measures (Allen, Hilgeman, & Allen, 2011; Carr, 2012; Daaleman, Emmett, Dobbs, & Williams, 2008; Kelley et al, 2011; Nicholas, Langa, Iwashyna, & Weir, 2011; Wicher & Meeker, 2012; Winter, Dennis, & Parker, 2007). African American individuals use the highest amount of intensive care and lowest amount of hospice care at the end of life, compared to other races (Hanchate, Kronman, Young-Xu, Ash, & Emanuel, 2009).…”

“…Among these, the following factors are noteworthy: familial and individual belief systems (Campbell & Ash, 2007; Mazanec, Daly, & Townsend, 2010), socialization and culture (Bullock, 2011; Johnson, Kuchibhatla, & Tulsky, 2009), spirituality and/or religion (Carr, 2012; Nath, Hirschman, Lewis, & Strumpf, 2008), and events in history (e.g., the Tuskegee Syphilis Study and Henrietta "HeLa Cells" Lacks Story) that contribute to mistrust of U.S. health care systems (Campbell & Ash, 2007; Mazanec et al, 2010). These factors make it increasingly important for health care providers to approach all patients as individuals, without assumptions or judgment regarding their care choices (Institute of Medicine [IOM], 2015).…”

Is Death “The Great Equalizer”? The Social Stratification of Death Quality in the United States

“…I control for demographic, health, and psychosocial characteristics that have been found elsewhere to be correlated with SES and both death quality and ACP (Carr 2003(Carr , 2012Carr and Khodyakov 2007). Analyses predicting death quality include a limited set of controls, given the relatively small samples of bereaved spouses; controls are added for age, gender, race (in CLOC and NJEOL), number of children, survivor depressive symptoms, death suddenness, and decedent's age and cause of death.…”

“…Furthermore, the effects of education (CLOC, WISTFL) and home ownership (WLS, NJEOL) were highly consistent across studies, even though data collection took place across three decades and three different samples, suggesting that patterns have not changed markedly over time. One potential explanation for SES disparities in pain level may be that persons with fewer socioeconomic resources are less likely to engage in ACP (Carr 2012), which is associated with higher rates of hospice and palliative care (Nicholas et al 2011;Silveira, Kim, and Langa 2010). Thus, the analyses now focus in-depth on SES (WLS) and race (NJEOL) disparities in rates of ACP.…”