Lessons from the end of life in the program of all-inclusive care of the elderly

Advance Care Planning in a Frail Older Population

This study examines the process of advance care planning in managed care programs serving the frail elderly and assesses the contributions of individual versus program characteristics on choices made. Data about 3,548 participants in nine programs were obtained. Logistic regressions examine associations between independent variables and end-of-life treatment choices. Interviews with the programs’ medical directors augment quantitative analysis. When all of the known participant characteristics are accounted for, substantial amount of variation attributable to the program-indicator variable remains. Program effect explains 36% of the variation in do-not-resuscitate choice, 66% in the choice of artificial feeding, and 50% relating to the presence of health care proxy. The variation in treatment choices attributable to the program of enrollment and the interviews with the medical directors suggest that provider practice styles are important in determining patients’ choices at the end of life. Interventions to enhance advance care planning should target providers of care.