End-of-Life Planning in a Family Context: Does Relationship Quality Affect Whether (and With Whom) Older Adults Plan?

At the end of life, most older adults suffer from chronic illness, physical discomfort, and compromised cognitive functioning. Under such conditions, they may be incapable of making decisions about their own medical treatments (Silveira, Kim, & Langa, 2010). Decisions about accepting or rejecting treatments often are left to family members who may not know the patient’s preferences or who may disagree about an appropriate course of care. To help ensure that their end-of-life treatment preferences are articulated and heeded by care providers, people can complete advance care planning (ACP) when they are still cognitively intact. ACP comprises formal and informal components: formal ACP includes a living will, a legal document specifying the medical treatments one would like to receive, and a durable power of attorney for health care (DPAHC), which designates a person to make decisions on behalf of an incompetent patient. Informal planning refers to discussions about specific treatment preferences and general values. Practitioners concur that planning is most effective when the formal documents are executed following informal discussions with those persons who may represent the patient in the decision-making process (Doukas & Hardwig, 2003). The efficacy of ACP may depend on the cooperation, knowledge, and participation of family members (Kehl, Kirchhoff, Kramer, & Hovland-Scafe, 2009). Family structure, including marital and parental statuses, affects both whether one engages in ACP and whom one names as DPAHC (Carr & Khodyakov, 2007; Kahana, Dan, Kahana, & Kercher, 2004). However, previous studies have not investigated the extent to which the quality of one’s relationships with spouse and children affect whether, how, and with whom older adults prepare for end-of-life care. This partly reflects the fact that studies of ACP historically were based on clinical samples, often of single disease groups, and thus do not obtain rich, comprehensive measures of family relationships. Our study uses data from the Wisconsin Longitudinal Study (WLS), a long-term study of aging that obtains detailed measures on ACP along with general questions assessing family functioning, parent–child relationships, and marital relations; as such, our study represents a first step at exploring the impact of family context on older adults’ end-of-life preparations. Study Aims The WLS obtained reports from relatively healthy older adults (aged 64–65 years) about their ACP, specific DPAHC designations, relationship quality, and potential confounds including socioeconomic status (SES) and health. These data enable us to explore associations between both positive and negative aspects of family relationships and two distinct ACP outcomes: one’s general planning strategy (i.e., discussions only, both formal and informal planning, or neither) and whom one appointed as DPAHC (i.e., spouse, child, other, or none). We expect that persons reporting greater marital satisfaction and more emotional support from children are more likely to engage in either of the two most effective types of ACP: discussions alone or a two-pronged approach comprising both formal and informal preparations. Similarly, we expect that a better quality relationship with a particular family member will increase the likelihood of that person being appointed DPAHC. These hypotheses are consistent with social support and control theories. The former states that individuals with high-quality relationships may be more highly motivated to engage in protective health behaviors (such as ACP) for the good of their family members. They also may feel encouraged to engage in ACP, a potentially stressful activity, due to the emotional support they receive from family (House, Landis, & Umberson, 1988). Social control perspectives, by contrast, emphasize that significant others may directly regulate, monitor, or urge a loved one’s health behaviors (Lewis & Rook, 1999). The potential impact of strained family relations, operationalized here as criticism from children, is more complex. Criticism from children could increase the likelihood of both ACP and selecting an adult child as DPAHC, if parents interpret such critical interactions as a concerned child’s way of offering assistance. Conversely, if such critical encounters are perceived to be an indicator of discord rather than concern, then frequent criticism may dissuade a parent from naming the child as DPAHC. Unfortunately, our data do not capture a parent’s interpretation of their child’s motivation for being critical; however, we can explore whether such critical exchanges increase or reduce the odds of both ACP and specific DPAHC appointments. All analyses are adjusted for demographic (i.e., sex, number of children), SES (i.e., education, income), and health (i.e., self-rated health, depressive symptoms, hospitalizations) characteristics to account for potentially spurious associations between relationship quality and ACP. Prior studies reveal that these background characteristics are associated with both family relationship quality in later life (Silverstein & Giarrusso, 2010) and ACP (Carr & Khodyakov, 2007). We also adjust for the quality of relationships with friends and more distant family members; these other sources of support may be compensatory and may encourage ACP even if one’s relationships with spouse and children are problematic.