Socioeconomic Status and Advance Care Planning in the ICU

2017 - 4 August – Diversity
Amelia Barwise, MD, BCh, BAO, MS; Michael E. Wilson, MD
Learn about socioeconomic status and advance care planning in the intensive care unit.

Socioeconomic status (SES) is used to describe the social standing of individuals and is usually based on factors such as income, education, and occupation. Compared to patients with higher SES, patients with lower SES have less income, less education, less desirable occupations, less medical insurance and, in general, less financial access to medical resources. Lower SES has been shown to be an important independent predictor of poor health outcomes, including increased rates of several chronic diseases and increased stress, morbidity, and mortality.1 SES may confound, mediate, or moderate other demographic predictors of healthcare disparities, including racial, ethnic, religious, cultural, and language barriers.2–4

Advance care planning is a concept and service to help patients prioritize their treatment goals.5 It can encompass the documentation of preferences in either a living will or advance directive, designation of a power of attorney or a Physician Order for Life-Sustaining Treatment (POLST) or Medical Order for Life-Sustaining Treatment (MOLST). However, advance care planning may also involve simple discussions that do not lead to specific legally binding documents. Although there may be limitations to the effectiveness of advance care planning, it remains a cornerstone of end-of-life decision-making in the United States.6,7 Patients who have an advance directive are more likely to receive medical care that reflects their stated preferences than patients who do not have one.8,9 Respecting patient preferences is a vital component of quality end-of-life care, so good communication is also essential.10 Expensive and poor-quality care may result if advance care planning has not been done or if there is poor or suboptimal communication. Studies have noted lower family ratings of quality of dying in the ICU, with the effect mediated by lack of an advance directive.11

While low SES has been noted to negatively affect access to care, quality of care, and healthcare outcomes, its role in end-of-life decision-making and care and specifically advance care planning has not been extensively studied as a primary predictor. We conducted a singlecenter study that demonstrated lower use of advance directives among those in the lowest socioeconomic group as well as increased use of advance directives as SES improved.12 Previous work has shown that differences in familiarity with advance care planning terminology, knowledge of advance care planning, and non-completion of advance directives were mediated by socioeconomic factors.13

The mechanisms by which SES might influence patient attitudes about interventions at the end of life, including cardiopulmonary resuscitation, mechanical ventilation, and other aggressive life-sustaining treatments may be influenced by several factors. Those in lower socioeconomic groups may have less education, leading to health literacy issues that may be barriers to good communication14 as well as understanding of treatments, management options, and prognosis.

Disadvantaged and marginalized populations may have fundamentally different beliefs about the benefits of advance directives, perhaps based on their life experience. Due to limited opportunities, they may have a greater willingness to prolong life by accepting interventions that represent a chance, no matter how small, to do so.15 They may have different preferences, which we should respect. Some qualitative research has noted that communication barriers may contribute to ineffective advance care planning among vulnerable populations.16,17 Another likely explanation for lower use of advance directives is the logistic and financial barriers that may cause difficulties accessing the resources required to formulate a useful and workable advance directive or advance care planning services.

Given that a lack of advance care planning has been associated with costly, poor-quality care,18 the association of low SES with lower rates of advance care completion and documentation is concerning. It is possible that lower rates of advance directive completion for those in the lowest socioeconomic group may lead to care that may not fully honor patients’ wishes. We promote advance care planning to try to reduce suffering and needless unwanted care at the end of life. Lack of an advance directive or access to advance care planning may represent a true healthcare disparity.

Since January 2016, the Centers for Medicare and Medicaid Services has introduced two new Current Procedural Terminology (CPT) codes that allow physicians to bill for time spent discussing advance care planning. Patients do not need to subsequently have an advance directive documented but the incentivized payments serve as a means of promoting discussions about end-of-life issues and decision-making. This policy may mitigate economic issues for those with low SES, assuming they have access to healthcare. Encouraging discussions between providers and patients may be an effective means of improving delivery of value-concordant care to vulnerable patients at the end of life that reflects their preferences.19

Clinicians and researchers face several challenges when trying to understand the relationship between SES and advance care planning. The lack of data about SES and its impact on healthcare and health outcomes reflects a lack of consensus about what is considered an appropriate measure of SES and challenges with data collection. Individual SES has previously been approximated from data about housing, zip code, health insurance, income, education, and occupational characteristics.20,21 These static measures are often neither recorded in the electronic medical record nor maintained up to date, resulting in unreliable data that fails to capture social mobility. Due to the poor quality of individual-level SES measures, census-level or area-level SES/disadvantaged area-level indicators are frequently used as proxy measures (Area Deprivation index), which may not always be accurate.22 Measuring the quality and not simply the quantity of advance care planning discussions is challenging, as is identifying a good metric for assessing the quality of end-of-life care, death, and dying.​

Conclusion
SES is a much discussed but poorly understood and studied demographic predictor.3,23 It incorporates a variety of contextual factors, including education, occupation, income, and insurance. Lower SES may be associated with a variety of other factors that may be correlated with poor health outcomes such as race, ethnicity, religion, and inability to proficiently speak English. However, we should consider SES as a key independent patient-level marker of risk for poor outcomes, including end-of-life care. Measuring the quality of death and dying and the effects of SES will be important going forward as we continue to reflect on whether advance care planning and access to it changes the quality of end-of-life care for patients who are socioeconomically disenfranchised. Respecting patient preferences is a vital component of quality end-of-life care and requires good communication. Advance care planning should encourage clear communication. If lack of advance care planning reflects access or communication issues and not conscious preferences or choices, we should be concerned that we have identified a disparity in healthcare that we should address. 

References
1. Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff (Millwood). 2002 Mar-Apr;21(2):60-76.
2. Erickson SE, Vasilevskis EE, Kuzniewicz MW, et al. The effect of race and ethnicity on outcomes among patients in the intensive care unit: a comprehensive study involving socioeconomic status and resuscitation preferences. Crit Care Med. 2011 Mar;39(3):429-435.
3. Muni S, Engelberg RA, Treece PD, Dotolo D, Curtis JR. The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU. Chest. 2011 May;139(5):1025-1033.
4. Kwak J, Haley WE. Current research findings on end-of-life decision making among racially or ethnically diverse groups. Gerontologist. 2005 Oct;45(5):634-641.
5. Physicians ACo. Advanced Care Planning Implementation fo Practices. In: ACP, ed2015.
6. Gillick MR. Advance care planning. N Engl J Med. 2004 Jan 1;350(1):7-8.
7. Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010 Aug 17;153(4):256-261.
8. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010 Apr 1;362(13):1211-1218.
9. Brinkman-Stoppelenburg A, Rietjens JA, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med. 2014 Sep;28(8):1000-1025.
10. Covinsky KE, Fuller JD, Yaffe K, et al. Communication and decision-making in seriously ill patients: findings of the SUPPORT Project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc. 2000 May;48(5 Suppl):S187-S193.
11. Lee JJ, Long AC, Curtis JR, Engelberg RA. The influence of race/ethnicity and education on family ratings of the quality of dying in the ICU. J Pain Symptom Manage. 2016 Jan;51(1):9-16.
12. Barwise A, Gajic O, Wilson M, et al. Socioeconomic status plays a role in advance care planning among adults in the ICU [Abstract 542]. Crit Care Med. 2016 Dec;44(12):212.
13. Tripken JL, Elrod C, Bills S. Factors influencing advance care planning among older adults in two socioeconomically diverse living communities. Am J Hosp Palliat Care. 2016 Jan 1:1049909116679140.
14. Volandes AE, Paasche-Orlow M, Gillick MR, et al. Health literacy not race predicts end-of-life care preferences. J Palliat Med. 2008 Jun;11(5):754-762.
15. Curtis JR, Vincent JL. Ethics and end-of-life care for adults in the intensive care unit. Lancet. 2010 Oct 16;376(9749):1347-1353.
16. Lifshitz H, Klein PS, Cohen SF. Effects of MISC intervention on cognition, autonomy, and behavioral functioning of adult consumers with severe intellectual disability. Res Dev Disabil. 2010 Jul-Aug;31(4):881-894.
17. Born W, Greiner KA, Sylvia E, Butler J, Ahluwalia JS. Knowledge, attitudes, and beliefs about end-of-life care among inner-city African Americans and Latinos. J Palliat Med. 2004 Apr;7(2):247-256.
18. Huang IA, Neuhaus JM, Chiong W. Racial and ethnic differences in advance directive possession: role of demographic factors, religious affiliation, and personal health values in a national survey of older adults. J Palliat Med. 2016 Feb;19(2):149-156.
19. AMA Wire. Advance care planning could become a more routine part of care. Chicago, IL: American Medical Association; 2015 Jul 14.
20. Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167-194.
21. Juhn YJ, Beebe TJ, Finnie DM, et al. Development and initial testing of a new socioeconomic status measure based on housing data. J Urban Health. 2011 Oct;88(5):933-944.
22. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000 May 17;283(19):2579-2584.
23. Eisner MD, Blanc PD, Omachi TA, et al. Socioeconomic status, race and COPD health outcomes. J Epidemiol Community Health. 2011 Jan:65(1):26-34.