Racial and state differences in the designation of advance directives in nursing home residents

OBJECTIVES: To examine racial and state differences in the use of advance directives and surrogate decision-making in a nursing home population. DESIGN: A retrospective cohort study. SETTING: Nursing homes in the states of California (CA), Massachusetts (MA), New York (NY), and Ohio (OH). PARTICIPANTS: Nursing home residents: 130,308 in CA, 59,691 in MA, 112,080 in NY, and 98,954 in OH. MEASUREMENTS: Minimum Data Set information concerning resident race and whether or not residents have a living will (LW), a do not resuscitate (DNR) order, or a surrogate decision-maker (SDM). RESULTS: The proportion of LWs, DNR orders, and SDMs varied significantly (P < .0001) by racial categories in each state. In general, whites were distinctly different from other racial categories. Whites were significantly more likely to have a LW (odds ratio (OR) = 1.9 (CA), OR = 2.2 (NY), OR = 4.9 (OH)), a DNR order (OR = 2.4 (CA), OR = 2.4 (MA), OR = 3.3 (NY), OR = 3.2 (OH)), and a SDM (OR = 1.1 (CA), OR = 1.2 (NY), OR = 1.6 (OH)) than were nonwhites, after adjusting for potentially confounding factors. Significant state differences (P < .0001) were observed in LWs, DNR orders, and SDMs and were most pronounced in residents of Ohio, who were significantly more likely to have a LW than were residents in other states (OR = 9.3). CONCLUSIONS: Various resident characteristics explain some of the racial differences, although whites are still more likely to have a LW, a DNR order, or an SDM independent of various resident characteristics included in the adjusted analyses. This pattern is observed in all states, although the ORs varied by state. Some of these differences may be due to distinct cultural approaches to end-of-life care and lack of knowledge and understanding of advance directives. The distinctly higher rates of LWs among all racial groups in Ohio than in other states suggest that states can potentially increase the use of advance directives through intervention.