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Older U.S. adults face at least 26 unique issues that can interfere with advance care planning, according to researchers from the University of California, San Francisco.

Investigators surveyed 1,241 English- and Spanish-speaking adults, aged 55 years and older, in two San Francisco public/Department of Veterans Affairs hospitals. All had two or more chronic conditions, 36% had limited health literacy and 36% spoke Spanish. Prior advance care planning documentation was confirmed via chart review.

Fully 91% of participants responded that they had at least one barrier to initiating advance care planning. When compared with their peers who reported none, those study participants were more likely to be Spanish-speaking, and many said they were from a racial/ethnic minority group (76% versus 53%). Nearly half had fair to poor health, and more than a third had limited health literacy. 

Barriers to having plans in place were found at the patient, family/friend and clinician/system level. The most common reasons patients did not initiate or choose to engage in discussions about the subject were discomfort when thinking about advance care planning (60%), a desire to leave healthcare decisions to God (44%), and not wanting to burden friends and/or family (33%). Approximately a third or more assumed that friends and/or family or their doctors already knew their preferences. Mistrust was reported by 37% of the respondents.

Perhaps not surprisingly, participants who reported barriers were less likely to have advance care planning documentation, wrote senior author Rebecca L. Sudore, M.D.

“Barriers must be considered when developing customized advance care interventions for diverse older adults,” Sudore and colleagues concluded.

Full findings were published in the Journal of the American Geriatrics Society.