Disparities in Advance Care Planning: Did COVID-19 Change Anything?

Rates of advance care planning (ACP) are lower and preferences for life-prolonging treatment are higher among Black compared to White older adults. We examined whether these differences persisted during the COVID-19 pandemic.

Between February 2021 and September 2022, we conducted a cross-sectional COVID-19-focused survey of seriously ill adults ≥ 65 years in 10 primary care clinics participating in a clinical trial of two ACP interventions. Logistic regression models examined associations between COVID-19 related ACP discussion (defined as discussions with family, friends, or doctors about COVID-related medical care) and treatment preferences if very sick with COVID-19 (life-prolonging treatment, comfort care, trial of life-prolonging with transition to comfort care if no improvement) overall and by race, controlling for baseline characteristics.

Among 428 participants (55.9% Black, 44.2% White; mean age 74.6), 25% reported discussing COVID-19 treatment preferences with family/friends and 6% with doctors. Most reported no change in willingness to participate in ACP due to the pandemic, though increased willingness was more common among Black than White participants (22.4% vs. 14.0%, p = 0.016). Despite this, COVID-19-related ACP discussion did not differ by race (family/friends: 22.7% vs. 28.3%, p = 0.19; doctors: 6.9% vs. 4.8%, p = 0.37). Most seriously ill older adults preferred a time-limited trial of life-prolonging treatment (71% White, 56.2% Black); though preferences varied by race (p < 0.0001); Black participants compared to White participants more often preferred life-prolonging treatment (28.5% vs. 10.3%). In adjusted models, race was not associated with COVID-19-related ACP discussion (OR 0.72, 95% CI 0.44-1.18), while preferences for life-prolonging treatments predicted greater COVID-19 related ACP discussion (OR 1.98, 95% CI 1.14-3.44).

In contrast to pre-pandemic ACP research, no racial differences were observed in COVID-19-related ACP discussion, though differences in treatment preferences persisted. These findings underscore the need for culturally responsive, context-sensitive ACP approaches among seriously ill older adults.