Advance care planning is a complex process that necessitates discussion between patients, their loved ones, and their physicians. In our multi-ethnic, multi-lingual sample of hospitalized patients, only 41% of patients reported having an advance care planning discussion with a hospital physician. While this is improved from previous studies that documented use of advance care planning discussions among seriously ill hospitalized patients to be less than 25%, [7
] the prevalence remains disturbingly low. In addition, a third of participants who reported having had ACP discussion when interviewed in the hospital did not recall having had that discussion when interviewed in the month following discharge. This may be in part because the participant’s health had improved enough that the discussion was no longer salient; however, it may also be indicative of low-efficacy discussions.
We found that comorbidity score was significantly associated with increased use of advance care planning discussions, and this finding was robust to adjustment for time-period and recruitment site. Physicians have been recognized as being in the best position to initiate and guide advance care planning discussions [8
], and research indicates that patients with chronic illness are in particular need of advance care planning [2
]. Therefore, it is not surprising, and is even encouraging, that clinical information such as a high comorbidity score is associated with a physician initiating such a discussion. We also found substantially higher use of ACP discussions at the academic medical center compared to the safety net institution; while this finding is at least in part related to differences in patient co-morbidity, it is also consistent with other research documenting variation in the use of ACP or code status discussions by hospital site and suggests the strong role of local culture in their use [10
Racial and ethnic minorities have lower rates of documented advance directives compared to Whites [3
], and incur higher healthcare cost due to higher rates of intensive treatment at the end of life [4
]. While distrust and cultural specific attitudes are thought to play a role in making advance directives more problematic particularly among less acculturated adults [3
], it is unclear if more intervention at the end of life is due to preference or to ineffective communication about the utility of these interventions or palliative options. [4
] We hypothesized that cultural differences and language barriers may in some way contribute to decreased physician use of advance care planning discussions with their minority patients. In our study, however, we did not find an association between level of formal education, ethnicity, English proficiency or, for immigrant participants, length of time living in the US and patient report of advance care planning discussion. These findings suggest that in this hospitalized patient sample, these factors do not significantly influence patient reports of physician use of advance care planning discussions. It is possible that ACP discussions are only used or relevant in the care of patients when there are medical problems that indicate a high likelihood of significant clinical worsening. However, the sample size limits our ability to definitively state that among older, less educated LEP patients, there are no differences in ACP discussions.
Our results should be viewed in light of several limitations. While we did not observe differences by age, the overall young age of patients at the safety net hospital likely influenced physicians against the use of advance care planning discussions and contributed to lower rates of ACP discussion. Also, we did not have access to additional patient information, such as severity of acute illness, which may be a major factor in physician decision to discuss advance care planning during hospitalization, and has been used in prior studies [7
]. Lastly, we relied solely on patient report of discussions, which may be subject to recall bias; however, patient participation in, understanding and recall of these discussions ultimately is the most important outcome.