A Cohort Study of Advance Directives in Electronic Health Records and End-of-Life Outcomes

Advance directives (ADs) are intended to document patient preferences for future care, including end-of-life (EOL). Knowledge of the impact of electronic health record (EHR)-documented ADs on actual care experiences is limited.

This is a retrospective cohort analysis of 2850 patients aged ≥ 65 years who died during a cluster-randomized trial of the impact of advance care planning (ACP). Subgroups included gender, marital status, patient portal access, dementia, and race. A total of 553 (19.4%) of the deceased patients had an EHR-documented AD 6 months prior to death. The setting was 51 primary care practices in two health systems in the Maryland and Washington, DC areas.

To examine the association between EHR-documented ADs and EOL experiences, a retrospective cohort study of older adults who died between September 2020 and October 2023 was conducted. Multilevel logistic regression models analyzed whether an EHR-documented AD at least 6 months before death was associated with potentially burdensome EOL care in the last 6 months of life and in-hospital death.

Among 553 decedents who had an EHR-documented AD at least six months before death (mean [SD] age 82.5 (8.8)); 311 were women [56.2%]; 203 [36.7%] had a diagnosis of dementia, 128 (23.1%) were Black, and 400 (72.3%) were White [Correction added on 18 June 2026, after first online publication: The preceding sentence has been amended in this version.]. Patients with an AD in the EHR were less likely to experience potentially burdensome EOL care (110 (19.9%) vs. 616 (26.8%); aOR = 0.75) and in-hospital death (128 (23.2%) vs. 738 (32.1%); aOR = 0.69). Effects persisted both before and after adjusting for demographics, comorbidities, healthcare utilization, patient portal access, organization, and whether the clinic was randomized to the ACP intervention or control. Significant associations were observed in married patients and those with portal access, but not among patients with dementia or Black race.

In this cohort study, EHR-documented ADs were associated with reduced potentially burdensome EOL care and a lower likelihood of in-hospital death.