• R Sean Morrison and Diane E Meier.
• Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY, USA. sean.morrison@mssm.edu
• Arch Intern Med. 2004 Dec 13;164(22):2421-6.

BackgroundPrevious studies have demonstrated low rates of advance care planning (ACP), particularly among nonwhite populations, raising questions about the generalizability of this decision-making process.ObjectiveTo explore factors that may influence patients' willingness to engage in ACP.DesignSurvey.SettingThirty-four randomly selected New York City senior centers.ParticipantsA total of 700 African American (n = 239), Hispanic (n = 237), and white (n = 224) adults 60 years and older.InterventionParticipants were administered a 51-item survey that assessed attitudes, beliefs, and practices regarding ACP.Main Outcome MeasuresAttitudes and beliefs about physicians' trustworthiness, fatalism, beliefs about surrogate decision making, and comfort discussing end-of-life medical care; factors associated with health care proxy completion; and health care proxy completion rates.ResultsMore than one third of the participants had completed a health care proxy. There were no significant differences in completion rates across the 3 ethnic groups. Respondents who had a primary care physician (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.2), were more knowledgeable about advance directives (OR, 2.0; 95% CI, 1.4-2.9), or had seen a friend or family member use a mechanical ventilator (OR, 1.5; 95% CI, 1.02-2.1) were significantly more likely to have designated a health care proxy. Respondents who were only comfortable discussing ACP if the discussion was initiated by the physician (OR, 0.6; 95% CI, 0.0-0.8) were significantly less likely to have completed a health care proxy.ConclusionsAfrican American, Hispanic, and white community-dwelling, older adults had similarly high rates of advance directive completion. The primary predictors of advance directive completion involved modifiable factors such as established primary care physicians, personal experience with mechanical ventilation, knowledge about the process of ACP, and physicians' willingness to effectively initiate such discussions. Some of the racial/ethnic differences in desire for collective family-based decision making that were observed in this study have implications for the evolution of ACP policy that respects and operationalizes these preferences.

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