Life-Stage and Contextual Factors of Advance Care Planning Among Older Adults With Limited Income

Abstract

Patient perspectives are essential to understand healthcare disparities such as low rates of advance care planning (ACP) among adults with limited income. We completed twenty semi-structured interviews using purposive and snowball sampling. Initial and final themes emerged from inductive inclusion of recurring codes and deductive application of the cumulative disadvantage theory. Four themes emerged: (1) structural, (2) life-stage, (3) social stressors and resources, and (4) individual stress responses and ACP readiness. ACP resources among participants included positive structural and social support and previous familial death experiences that were mitigated by stress avoidance and competing priorities. Structural resources and healthcare stressors should be addressed with policy and research to improve continuous healthcare participation and support early, comprehensive ACP.

Keywords: advance care planning; poverty; qualitative; socioeconomic status.

Figure 1.

Each theme on the left-hand side of the figure represents stressors and/or resources that affect coping with ACP (on the right). The social domain affects life-stage stressors and resources, and vice versa, by contributing to familial planning dynamics, communication, and contributing to ongoing life experiences. Structural stressors and resources also have a bidirectional relationship with the life-stage domain, particularly the healthcare interaction sub-theme, such that the healthcare quality and insecurity are age-dependent. Each coping type on the right is affected by these different thematic domains: 1. General resilience and problem-solving include the individual ability to adapt to stressors combined with robust resources across domains, 2. Avoidance was typically a gendered coping strategy and was influenced by a variety of stressors such as the lack of social support, lack of healthcare support, and competing financial concerns, 3. Those who sought social support were also supported by family and, sometimes, healthcare providers, and 4. Religious coping was influenced primarily by individual beliefs based on the life-stage domain (death-related experiences and familial planning practices). The dashed lines indicate possible relationships for future study but do not indicate confirmed mechanisms.