Caregiving preferences and advance care planning among older adults living with HIV.

With the increase in the US of the number of older adults living with HIV, more research is needed to understand the caregiving and advance care planning needs of this population. This descriptive study examined the relationship between social support and caregiving preferences and advance care planning. Older adults living with HIV were recruited from clinics in Los Angeles, CA and New Orleans, LA to complete cross-sectional surveys (n = 154). Logistic regression analyses were modeled to determine the characteristics associated with 1) preference for formal short-term term care, 2) preference for formal long-term care, 3) having at least one contact for emergency care, 4) having an advance directive or living will, and 5) having a healthcare proxy or agent. The mean age was 56.8 years. The majority of participants indicated a preference for informal support for both short-term (73.4%) and long-term care (66.2%), 13.2% had no one they could call for emergency care, 26.0% had an advance directive/living will, and 30.5% had a healthcare proxy/agent. In adjusted models, greater social support was associated with preference for informal short-term care and with having at least one emergency contact. Findings suggest that older adults living with HIV prefer informal sources of support for their caregiving needs despite having small social networks and individuals with limited social networks are particularly vulnerable due to lack of access to caregivers in sudden or unexpected health situations.

Do older adults with Alzheimer's disease engage in estate planning and advance care planning preparation?

OBJECTIVES: This study investigated the estate planning and advance care planning (ACP) of older adults diagnosed with Alzheimer's disease (AD) for the presence of (1) a valid will, (2) a durable power of attorney for health care, and (3) a living will. METHOD: We analyzed 10,273 adults aged 65 and older from the 2012 Health and Retirement Study (HRS) using multilevel logistic regression. RESULTS: We found that a diagnosis of AD was significantly associated with the ACP variables. Older adults with AD were more likely to assign a durable power of attorney for health care and have a written living will than older adults without an AD diagnosis. However, we found no significant association between a diagnosis of AD and having a valid will. These findings were robust when adjusting for demographic and socioeconomic variables. Other factors decreased engagement in estate planning and ACP, including lower socioeconomic status, being male, and being a minority. CONCLUSION: Our findings suggest that a diagnosis of AD is associated with more engagement in ACP for individuals and their families, but important barriers exist for people with fewer resources.

[Living will, durable power of attorney and legal guardianship in the trauma surgery routine : Data from a geriatric trauma center]. / Patientenverfügung, Vorsorgevollmacht und gesetzliche Betreuung im unfallchirurgischen Alltag : Zahlen aus einem alterstraumatologischen Zentrum.

BACKGROUND: Due to the increasing number of elderly patients, trauma surgeons are often confronted with end-of-life treatment decisions. Advance directives can help reduce the lack of clarity in those situations. OBJECTIVES: The aim of this study was to identify the presence of living wills, durable power of attorney, legal guardianship and appointment of guardianship in the geriatric trauma center of a university hospital. MATERIALS AND METHODS: The data of all patients treated in our geriatric trauma center from 01/01/2013 to 03/31/2014 were analyzed regarding the presence of a living will, durable power of attorney, legal guardianship and appointment of guardianship as well as the procedure of documenting those items. RESULTS: Out of 181 patients, 63 % (n = 114) had one or more of these documents. Most frequently used was the durable power of attorney in 33 % (n = 59), followed by a living will in 27 % (n = 48), legal guardianship in 20 % (n = 37) and appointment of guardianship in 7 % (n = 12). The existence of those documents was recorded in 88 % (n = 100) of patients within 24 h after admission; documentation in the medical records was found in 58 % (n = 66). CONCLUSION: A large proportion of patients had one or more of the documents named above. In this respect, standardized documentation of advance directives in the medical record is an important issue for all persons involved.

Advance care planning and proxy decision making for patients with advanced Parkinson disease.

OBJECTIVES: To examine advance care planning practices and proxy decision making by family healthcare proxies for patients with advanced Parkinson disease (PD). METHODS: Sixty-four spouses and adult children, self-designated as a/the healthcare proxy for advanced patients with PD, participated in a cross-sectional survey study. RESULTS: Sixty patients with PD (95%) had completed a living will, but only 38% had shared the document with a physician. Among three life-support treatments--cardiopulmonary resuscitation (CPR), ventilator, and feeding tube--47% of patients opted for CPR, 16% for ventilator, and 20% for feeding tube. Forty-two percent of proxies did not know patients' preferences for one or more of the three life-support treatments. Only 28% of proxies reported that patients wanted hospice. Patients who shared advance directives with a physician were significantly less likely to choose CPR and a feeding tube and they were more likely to choose hospice. In a hypothetical end-of-life (EOL) scenario, the majority of proxies chose comfort care as the EOL goal of care (53%) and pain and symptom management only as the course of treatment option (72%); these proxy choices for patients, however, were not associated with patients' preferences for life support. Patients' proxies preferred a form of shared decision making with other family members and physicians. CONCLUSIONS: Advance care planning is effective when patients, families, and healthcare professionals together consider future needs for EOL care decisions. Further efforts are needed by healthcare professionals to provide evidence-based education about care options and facilitate advanced discussion and shared decision making by the patient and families.

[The living will. An analysis of state of knowledge of patients in the HELIOS hospital Leisnig]. / Die Patientenverfügung. Eine Wissensstandanalyse von Patienten im HELIOS Krankenhaus Leisnig.

On September 1, 2009, the Guardianship Law (Betreuungsgesetz) changed for the third time. Thus, the rights of the people living in Germany have been improved with reference to the preventive instruments. The aim of the work was to find about the subject to what extent patients understand the subject and how many of them have such a preventive document. The area of research has been examined on the basis of a standardized questionnaire drawn up by means of anonymous data collection in the quantitative research design. After the pretest, the survey was done in form of a documented Face-to-face-questioning in the HELIOS hospital Leisnig. The sample size comprised 139 patients from which 84 patients (37 female, 47 male) agreed with the survey. 25 percent of the questioned patients knew the law of living will (Patientenverfügungsgesetz) and 27 percent knew about the content of preventive instruments. 46.4 percent of the surveyed patients, aged between 70 and 75, had at least one preventive instrument. 63.1 percent of the patients believed that a living will has to be in a written form. 21.4 percent said that, in addition, the document has to be authenticated by a notary public. A study by van Oorschot claims that between ten and 15 percent of the people living in Germany have a living will (van Oorschot 2008, p. 443, Sahm & Schroeder 2009, p. 98). The results of this study show a much higher proportion of existing living wills. For the majority of respondents a preventive instrument plays still a minor role, but 46 percent of the population already use a preventive instrument to make provisions for themselves. 27 percent did express their will in theform of a living will. Nevertheless, the survey shows a lack of knowledge of the correct handling of the living will.

Advance care planning among Colombian, Mexican, and Puerto Rican women with a cancer diagnosis.

PURPOSE: Limited knowledge exists pertaining to advance care planning (ACP) among Colombian, Mexican, and Puerto Rican women with a cancer diagnosis living in Central Florida, in the USA. The purpose of the study is to identify factors that facilitated the completion of ACP and decisions making patterns among the three groups of Latinas. METHODS: The research method used was an exploratory qualitative in-depth open-ended semi-structured interview with a grounded theoretical approach and thematic analysis. The interviews were conducted in Spanish with a purposeful sample of 45 Latinas (15 in each group) diagnosed with cancer. RESULTS: A total of ten women (22 %) in the study documented at least one form of ACP. Thirty-five women identified obstacles to accessing information regarding ACP, relating this to insurance and financial factors. Among the Colombian women, one completed a living will, health care surrogate, and power of attorney (all forms of ACP), and three just a living will. Two Puerto Rican women completed all, two a living will, and one both a living will and an enduring power of attorney. Only one Mexican woman completed a living will. CONCLUSIONS: This study identifies a knowledge gap regarding ACP among Latina women with cancer diagnosis living in Central Florida, in the USA. Differences between the three groups exist as a result of migration/immigration history, family support, education, English language proficiency, income, knowledge gaps, and information ascertained by medical and health professionals. These differences contribute to their readiness, receptiveness, and willingness to engage in documenting a living will, a health care surrogate, and an enduring power of attorney for health decisions.

[Living wills of residents in nursing homes - which treatment situations and treatment measures are decreed?] / Patientenverfügungen von Bewohnenden in Pflegeeinrichtungen ­ welche Behandlungssituationen und Behandlungsmaßnahmen werden vorausverfügt?

BACKGROUND: The possibility of using a living will to influence later treatment in the event of incapacity to consent is nowadays an important element in safeguarding patients' autonomy at the end of life. Refusing or consenting treatment measures in advance of treatment is of particular importance for nursing home residents, not only against the background of the COVID-19 pandemic. METHODS: We conducted a survey of all resident-documents in 13 nursing homes of different sizes and service providers in the city and district of Wuerzburg. The documents were analysed according to a deductive-inductive procedure using categorical summaries and descriptive frequency counts. RESULTS: In 265 recorded living wills, 2072 treatment situations and 1673 treatment measures could be identified. Residents largely agree to symptom-relieving and nursing measures and often reject life-prolonging or life-substaining treatment measures, the latter mostly being limited to specific, defined situations. The reference to certain treatment situations regarding resuscitation attempts, both in the form of refusal and consent, was identified in 88.6 % of the living wills. 62 % of the living wills could be assigned to a template. DISCUSSION: The study provides information about the content of living wills of nursing home residents. It thus provides information on medical treatment preferences in the case of incapacity to consent and shows that treatment measures (including resuscitation) are mostly related to specific treatment situations.

Planning for future care needs: experiences of unmarried heterosexual and sexual minority women.

This study examined the experiences of legally unmarried, middle-aged and older sexual minority (e.g., lesbian, bisexual) and heterosexual women in planning for future care needs and long-term assistance. A total of 215 women (90 sexual minority women and 125 heterosexual women) 41-78 years of age completed a survey about long-term care planning strategies, including: (1) executing a will; (2) naming a health care proxy; (3) purchasing long-term care insurance; and (4) discussing potential living arrangements with at least one family member. Overall, 18.5% of women reported completing zero of the strategies, and 3.4% reported completing all four. Over half (59%) had completed at least two strategies. Women were most likely to have executed a will (68%) and named a health care proxy (61%). Both sexual minority women and heterosexual women were most likely to have talked to a family member of choice, rather than a biological family member about living with them if they were unable to care for themselves. Currently, serving as a health care proxy was an important correlate for having made long-term care plans and was particularly important for sexual minority women. Women who are not in traditional marriage relationships tend to adopt long-term care planning strategies that legally clarify and establish the nature of their important relationships.

Risk-reducing legal documents: controlling personal health and financial resources.

Every adult can eliminate the risk of losing control of personal health decisions and financial resources by having a last will and testament, health proxy, power of attorney, and living trust. Yet evidence suggests that less than a majority of adult Americans have these documents. We surveyed 900 adult Americans (25 plus years old) to determine what factors predict the possession of these risk-reducing documents. In total, 46% had a living will and testament, 32% a durable power of attorney, 30% a health proxy, and 18% a living trust. Events that prompt people with wealth to secure these documents, such as increasing age, getting married, having children, and experiencing a life-threatening event were the strongest predictors of having a will. These were also among the strongest predictors of having a health proxy, along with a personal history of being proactive, and a family history that fostered trust of attorneys. Affluence, age, and education were the strongest predictors of having a living trust, and the strongest correlate of having a durable power of attorney was having faced a life-threatening event, positive experiences with attorneys, and higher educational achievement.

[Advance health care directives as seen by surgical patients]. / Patientenverfügung aus der Sicht des chirurgischen Patienten.

BACKGROUND: Progressive health care implies progress also in physician/patient interaction, especially with regard to moribund patients and their relatives. Advance health care directives emerged from the desire to influence medical treatment even in borderline situations. In spite of the present political and public discussions in Germany, advance directives are rarely of much importance in everyday surgical practice. By means of questionnaires, this study aimed at the frequency of advance directives among the patients of a surgical hospital and at related influencing factors. METHODS: Between August 2007 and January 2008, 450 patients at our hospital were interviewed, prior to scheduled surgery, on the topic of advance health care directives by means of anonymous questionnaires. In addition to questions about the existence of or the intention to draw up advance directives, the study focussed particularly on the relationship between patient and attending physician. Patient-specific and sociodemographic data were collected as well. RESULTS: Of the patients interviewed, 16.7% stated they had drawn up advance directives, while 21.3% did not know about the possibility of drawing up such a document. A mere 9.7% of the patients interviewed saw no need for such directives, whereas the majority (65.3%) considered it an option. Among the factors influencing the drawing up of advance directives, age and prior experience with severe disease figured significantly. Of the patients interviewed, 64.8% wished for more information on the topic of advance health care directives and health care proxies. The wish was expressed by 80.1% of patients that the attending surgeon mention the topic prior to surgery. CONCLUSIONS: Although the proportion of patients that draw up advance health care directives continues to be less than one fifth, surgical patients have a great need for information regarding the topic. Surgical hospital personnel should also set themselves to this task.

The importance of living wills and advance directives.

Living wills and advance directives are important components of patients' medical records, which all too often do not indicate the appropriate palliative care measures the patient desires. A review of the current literature indicates that approximately 85% to 95% of the population does not have adequate advance directives or palliative care measures written in their medical record. Furthermore, these orders may not follow the patient when he or she is transferred to other facilities for intermittent care. Unwanted tracheal intubations can be both costly to the facility and distressing to the patient and family members. By instituting a change in policy, organizations can ensure that patients' wishes for end-of-life care are met appropriately. In addition, nurses should advocate for a centralized database at the political level.

Effect of Living Wills on End-of-Life Care: A Systematic Review.

OBJECTIVES: To comprehensively assess the effect of a living will on end-of-life care. DESIGN: Systematic review with narrative analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. PARTICIPANTS: All interventional and observational studies were included, excepting those with fictive cases. Included studies were conducted in adults with and without living wills, excluding individuals with specific psychiatric living wills. MEASUREMENTS: Two authors independently extracted study and participant characteristics and outcomes related to end-of-life care (place of death, hospitalization and intensive care unit management, life-sustaining treatments, restricted care). Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool. RESULTS: From 7,596 records identified, 28 observational studies were included, 19 conducted in the United States, 7 in Europe, and 1 each in Canada and Australia. Place of death was assessed in 14 studies, life-sustaining treatments in 13, decision for restricted care in 12, and hospitalization in 8. Risk of bias was serious for 26 studies and moderate for 2. Twenty-one studies reported significantly less medical management for individuals with a living will, 3 reported more medical management, and the difference was not significant in 37. CONCLUSION: Methodological quality of included studies was insufficient to offer reliable results. The effect of living wills appears limited in view of the importance and direction of potential biases. Further studies including larger populations, considering main confounding factors, and documenting the real presence of a living will in medical records are necessary to reach stronger conclusions on the effect of living wills on end-of-life care. J Am Geriatr Soc 67:164-171, 2019.

End-of-Life Care Planning: The Importance of Older Adults' Marital Status and Gender.

Background: As the U.S. population ages, dramatic shifts are occurring in the proportion of older adults who are divorced and widowed. Health status and behaviors are known to differ across marital status groups, yet research on end-of-life (EOL) care planning has only compared married and unmarried persons, overlooking differences between divorced and widowed individuals, by gender. Objective: This study aimed to examine marital status differences in EOL care planning by comparing the likelihood of discussions about EOL care, designation of medical durable power of attorney (MDPOA) for health care decisions, and completion of a living will for married, divorced, and widowed older adults, by gender. Methods: Analyses used data from the U.S. Health and Retirement Study for 2243 adults (50 years of age and older), who died during the course of the study. Post-death, proxy respondents reported on the decedents' EOL care discussions, living will completion, and establishment of an MDPOA. Multivariate regressions were estimated to test differences in care planning across marital status groups, for men and women. Results: Divorced men were less likely than married men to have had care discussions and to have engaged in any of the three planning behaviors. Widowers were more likely to have established an MDPOA. Both divorced and widowed women were more likely to have performed any of these EOL planning activities than married women. Conclusions: Divorced men and married women are at risk for lacking EOL care planning. Practitioners are encouraged to discuss the importance of such planning as they encounter these at-risk groups.

Palliative care needs of patients with neurologic or neurosurgical conditions.

BACKGROUND AND PURPOSE: Many patients with non-cancer diagnoses utilize palliative services. There is little data on the palliative care needs of patients with neurologic and neurosurgical disorders. METHODS: Retrospective chart review. Log sheets which contain all patients seen between January 2004 and 2007 by palliative medicine (PM) were reviewed. Patients with neurologic or neurosurgical disorders were identified and their in-patient charts and electronic records reviewed. Patients with cancer were excluded. RESULTS: A total of 1429 cancer patients were seen by PM. Neurologic or neurosurgical diseases were the second most common in patients seen by the PM service, in 177 cases. Forty-seven patients were excluded. Complete data was collected on 129 patients. Mean age was 70. Seventy-one (55%) were female. The most common neurologic diagnosis was ischemic stroke in 33 (26%). Seventy-five (58%) had symptoms recorded. Reasons for PM consultation included 'comfort measures' in 40 (39%) and 'hospice candidacy' in 38 (37%). The most common recommendation made by the PM service was morphine in 44 (42%). Sixty-three (49%) were deemed hospice appropriate. CONCLUSIONS: Our findings support the need for PM services for patients with various neurologic and neurosurgical disorders. Understanding these needs will allow for the tailoring of palliative care services to such patients.

Are we ready to utilize non-heart-beating donors for clinical allotransplantation in China?

The concept of brain death has not been accepted by the majority of Chinese. Importantly, it is not recognized as a legal entity. We have developed a non-heart-beating donation protocol based on literature searches (Medline, Ovid, and CNKI) and issues related to Chinese customs and ethics. The principles guiding protocol development included: separation of the decision to terminate life support from the donation decision, family-centered donation, freedom of conflict interest, and prohibition of organ sales. This protocol covers donation policy, potential donor identification and evaluation, family consent, determination of death, procurement, and special legal documents/organ distribution policy. A random survey was performed regarding donation. There have been several arguments about the development of this protocol. First, do donor family members have the right to make a decision to withdraw life support? Another issue is whether family members have the right to consent to donation without a will from the donor. Our survey found that over 96.1% of people do not have a will and have not discussed their interests in donation with family members. The last issue is whether the hospital can financially help for the funeral after donation. We have debated these issues nationwide with various opinions. We hope to find the right solutions through international debate. We believe that the use of non-heart-beating-donor organs has potential in China. We are hopeful that it will become a major organ source that is developed in such a way so as to be accepted internationally as well as in China.

Health-Care Provider Personal Religious Preferences and Their Perspectives on Advance Care Planning With Patients.

OBJECTIVE:: To understand how health-care providers' (HCPs) religious preferences influence their willingness to undertake advance care planning (ACP) with patients and their acceptance of other HCP's involvement. METHODS:: Online anonymous survey distributed to HCPs in hospital, ambulatory offices, and hospice settings in Dayton, Ohio. We evaluated the associations of HCP religion with their personal ACP, willingness to facilitate ACP, and acceptance of other HCPs' ACP participation. RESULTS:: 704 respondents: nurses (66.2%), physicians (18.8%), other HCPs (15.0%), white (88.9%), and primarily Catholic (23.3%) or Protestant (32.0%). "No religion" was marked by 13.9%. Respondents were favorable to ACP with patients. Religious respondents were more likely to have a living will ( P = .035) and health-care power of attorney ( P = .007) and more accepting of clergy as ACP decision coaches ( P = .030). HCP's religion was not associated with willingness to facilitate ACP discussions. There were minor differences between Catholics and Protestants. CONCLUSIONS:: Personal religious preference is associated with HCP's own ACP but had little relationship with their willingness to facilitate ACP conversations with patients or acceptance of other professional types of HCPs involvement in ACP conversations. Regardless of religious affiliation, HCPs have interest in undertaking ACP and endorse other HCPs ACP involvement. As results of this study suggest that personal religious affiliation is not a barrier for HCPs engaging in ACP with patients, attempts to overcome barriers to increasing ACP should be directed to other factors.

Differences in the quality of the patient-physician relationship among terminally ill African-American and white patients: impact on advance care planning and treatment preferences.

BACKGROUND: Little is known about the quality of the patient-physician relationship for terminally ill African Americans. OBJECTIVE: To compare the quality of the patient-physician relationship between African-American and white patients and examine the extent to which relationship quality contributes to differences in advance care planning (ACP) and preferences for intensive life-sustaining treatment (LST). DESIGN: Cross sectional survey of 803 terminally ill African-American and white patients. MEASUREMENTS: Patient-reported quality of the patient-physician relationship (degree of trust, perceived respect, and joint decision making; skill in breaking bad news and listening; help in navigating the medical system), ACP, preferences for LST (cardiopulmonary resuscitation, major surgery, mechanical ventilation, and dialysis). RESULTS: The quality of the patient-physician relationship was worse for African Americans than for white patients by all measures except trust. African Americans were less likely to have an ACP (adjusted relative risk [aRR] = 0.66, 95%CI = 0.52-0.84), and were more likely to have a preference for cardiopulmonary resuscitation and dialysis (aRR = 1.28, 95%CI = 1.03-1.58; aRR = 1.25, 95%CI = 1.07-1.47, respectively). Additional adjustment for the quality of the patient-physician relationship had no impact on the differences in ACP and treatment preferences. CONCLUSIONS: Lower reported patient-physician relationship quality for African-American patients does not explain the observed differences between African Americans and whites in ACP and preferences for LST.

[Relevance of Living Wills During Post-Resuscitation Care]. / Stellenwert der Patientenverfügung in der Postreanimationsbehandlung.

Background There is hardly any evidence about the influence of living wills on acute life-threatening disease like out-of-hospital cardiac-arrest (OHCA). We therefore initiated this study to quantify the percentage of victims of OHCA who's living wills are available during post-resuscitation care. Methods All victims of OHCA who were admitted to our hospital between January 1st 2008 and July 31th 2016 were identified by analysis of our central admission register. Data from individual patients were collected from the patient's health records and anonymously stored on a central database. Results Altogether, there were 343 victims of OHCA admitted to our hospital between January 1st 2008 and July 31th 2016, including 16 patients (4.7 %) with living wills and 18 patients (5.2 %) with legal health care proxy. Survival rates were 31.2 % in patients with living wills, 27.8 % in patients with legal health care proxy and 33.3 % in patients without such a document. Conclusion In this study, the percentage of victims of OHCA with available living wills during post-resuscitation care was low. The presentation of living wills or legal health care proxies during post-resuscitation care of victims from OHCA was not equivalent to the patient`s death. Most often, discussion with relatives led to the decision to withdraw further therapy.

Frequency and determinants of advance directives concerning end-of-life care in The Netherlands.

In the USA, the use of advance directives (ADs) has been studied extensively, in order to identify opportunities to increase their use. We investigated the prevalence of ADs and the factors associated with formulation of an AD in The Netherlands, using samples of three groups: the general population up to 60 years of age, the general population over 60 years of age, and the relatives of patients who died after euthanasia or assisted suicide. The associated factors were grouped into three components: predisposing factors (e.g. age, gender), enabling factors (e.g. education) and need factors (e.g. health-related factors). We found that living wills had been formulated by 3% of younger people, 10% of older people, and 23% of the relatives of a person who died after euthanasia or assisted suicide. Most living wills concerned a request for euthanasia. In all groups, 26-29% had authorized someone to make decisions if they were no longer able to do so themselves. Talking to a physician about medical end-of-life treatment occurred less frequently, only 2% of the younger people and 7% of the older people had done so. Most people were quite confident that the physician would respect their end-of-life wishes, but older people more so than younger people. In a multivariate analysis, many predisposing factors were associated with the formulation of an AD: women, older people, non-religious people, especially those who lived in an urbanized area, and people with less confidence that the physician would respect their end-of-life wishes were more likely to have formulated an AD. Furthermore, the enabling factor of a higher level of education, the need factor of contact with a medical specialist in the past 6 months, and the death of a marital partner were associated with the formulation of an AD.

Concordance of Advance Care Plans With Inpatient Directives in the Electronic Medical Record for Older Patients Admitted From the Emergency Department.

CONTEXT: Measuring What Matters identified quality indicators to examine the percentage of patients with documentation of a surrogate decision maker and preferences for life-sustaining treatments. OBJECTIVES: To determine the rate of advance care planning in older adults presenting to the emergency department (ED) and translation into medical directives in the electronic medical record (EMR). METHODS: A convenience sample of adults 65 years or older was recruited from a large urban ED beginning in January 2012. We administered a baseline interview and survey in English or Spanish, including questions about whether patients had a documented health care proxy or living will. For patients admitted to the hospital who had a health care proxy or living will, chart abstraction was performed to determine whether their advance care preferences were documented in the EMR. RESULTS: From February 2012 to May 2013, 53.8% (367 of 682) of older adults who completed the survey in the ED reported having a health care proxy, and 40.2% (274 of 682) had a living will. Of those admitted to the hospital, only 4% (4 of 94) of patients who said they had a living will had medical directives documented in the EMR. Similarly, only 4% (5 of 115) of patients who had a health care proxy had the person's name or contact information documented in their medical record. CONCLUSION: About half of the patients 65 years or older arriving in the ED have done significant advance care planning, but most plans are not recorded in the EMR.