Advance Care Planning for Black and White Older Adults With Serious Illness: The EQUAL ACP Randomized Trial

Advance care planning (ACP) helps individuals communicate preferences for future medical care. Many adults do not participate in ACP, and Black adults are less likely than White adults to participate.

To compare the effectiveness of facilitated vs self-guided ACP interventions.

EQUAL ACP was a multisite, cluster randomized trial conducted in 10 primary care (n = 9) and geriatrics (n = 1) clinics in the South of the United States. Participants were community-dwelling Black and White adults 65 years or older with serious illness. Within each clinic and study group, participants were randomized to a racially concordant or discordant ACP facilitator.

Clinics were randomized to Respecting Choices First Steps, a facilitated ACP approach, or Five Wishes, a self-guided approach. Both were delivered by lay ACP facilitators.

ACP completion within 12 months after the baseline survey, defined as new formal (advance directive, clinician note, or orders for life-sustaining treatment form in the medical record) and/or new informal ACP (participant-reported discussion with family about end-of-life care preferences). The primary analysis compared the effectiveness of the self-guided approach with the facilitated approach within each racial group. Other analyses assessed interaction between race and treatment in the combined sample and the association of participant-facilitator racial concordance with ACP.

Of 791 participants, 427 were Black and 364 were White; 409 were in clinics with the facilitated approach and 382 in clinics with the self-guided approach. Among Black participants, 152 of 213 (71%) in facilitated clinics and 131 of 213 (62%) in self-guided clinics completed ACP within 1 year (adjusted risk ratio [RR], 1.15 [95% CI, 0.83-1.59]). Among White participants, 133 of 196 (68%) in facilitated clinics and 131 of 167 (78%) in self-guided clinics completed ACP (adjusted RR, 0.88 [95% CI, 0.65-1.18]). Among 789 in the pooled sample, 547 (69%) completed ACP, including 130 of 789 with formal ACP and 523 of 668 with informal ACP. In the pooled sample, the interaction between race and intervention group was significant (adjusted RR, 1.32 [95% CI, 1.03-1.69]), indicating greater effectiveness of the facilitated vs self-guided approach among Black relative to White participants. Participant-facilitator racial concordance was not associated with ACP in either racial group.

ACP completion within 1 year did not differ significantly between facilitated vs self-guided ACP approaches within Black or White racial groups.

ClinicalTrials.gov Identifier: NCT03516994.