Barriers to Completion of Health Care Proxies

Abstract

ADVANCE DIRECTIVES (health care proxies and living wills)^1-4 provide patients with a means to preserve some control over their medical care should decisional capacity be lost. Advance directives have not been uniformly used by different segments of the US population and studies have consistently shown a lower baseline prevalence of advance directive completion for African Americans and Hispanics compared with non–Hispanic whites (primarily with respect to living wills).^5-11 The reasons for this variability in completion rates are unclear. Ethnic differences in knowledge about advance directives,^8,10,12 differences in access to health care and associated opportunities to complete advance directives,^13-15 absence of appropriate surrogates,¹⁶ and concerns about placing undue burdens on surrogates¹⁷ have all been cited as potential explanations. It is also possible that members of disenfranchised ethnic groups perceive advance directives as a means of limiting their access to health care.¹⁰ Finally, it may be that advance directives are perceived as an unnecessary and overly formal approach to decisions that have traditionally rested with family members. The objective of this study was to explore differences regarding knowledge and completion of health care proxies among 3 ethnic and racial groups. To this end, we sought to identify confounding variables that might explain observed differences in the prevalence of advance directives, particularly health care proxies, among different ethnic groups.