Advance directives prior to COVID-19 diagnosis in a United States national healthcare system

Abstract

Background An advance directive (AD) document allows a patient to indicate their health care preferences and identify an agent to make decisions on their behalf if they lose their ability to communicate. Due to the substantially elevated risk of acute respiratory failure and death during the COVID-19 pandemic, ADs were especially relevant. The objective of this study was to describe AD completed prior to COVID-19 infection (COVID-19) among patients receiving care in a national healthcare system. Methods We conducted a cohort study of United States Veterans Health Administration (VA) patients with COVID-19 between March 2020 and December 2022. AD completion before COVID-19 was ascertained by progress note titles in the electronic health record. Covariates included age, sex, race/ethnicity, marital status, geographic region, health care utilization, calendar quarter of COVID-19, and VA COVID-19 (VACO) 30-day mortality index score. Results Among 422,028 COVID-19 patients (median age = 62 years; 88.5% male; 58.6% non-Hispanic White (NH-White), 23.3% non-Hispanic Black (NH-Black), 9.2% Hispanic), 67,970 (16.1%) had AD documentation which varied substantially across all covariates. AD completion increased with VACO Index quintiles ranging from 8.2 to 31.0%. In a model adjusted for covariates, relative to NH-White, NH-Black and Hispanic groups had decreased odds for AD (NH-Black odds ratio (OR)=0.77 (95% confidence interval 0.76–0.79); Hispanic OR=0.85 (0.82–0.87)). VACO index includes age, and both were strongly associated with AD completion. Women compared to men, and those who were widowed, separated/divorced and never married relative to people who were married, had increased AD completion. Conclusions AD completion was overall low, including among patients at high risk of mortality due to COVID-19. When controlling for age, risk for mortality and other covariates, men and people who identify as Black or Hispanic were less likely to have completed an AD. Investment in interventions to facilitate AD completion are needed, particularly among historically underrepresented populations.