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Only 42% in HIV group have an advance directive immediately before death
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9th International Workshop on HIV and Aging, September 13-14, 2018, New York
Mark Mascolini
Only 4 in 10 HIV-positive people who died at a single center in 2013-2017 had completed an advance directive, including many people with a terminal condition [1]. About three quarters of the group had assigned medical power of attorney (MPOA).
Advance directives and MPOAs are critical documents for all aging people, and especially those with shorter than average life expectancy, like people with HIV. Advance directives ensure that a person's medical wishes are observed if that person becomes incapable of communicating with health professionals. MPOAs assign medical decision making for a nonresponsive individual to another person.
Aging HIV-positive people may by less likely to create these legal instruments because they lack the social support that often encourages advance directives and MPOAs: often partners or close friends have died or the individual has become estranged from family members. An earlier retrospective review by some of these researchers found that only 134 of 588 people (23%) attending the University of Wisconsin HIV clinic had an advance directive [2].
University of Colorado investigators conducted the new study to see if advance directive and MPOA completion rates might be higher in HIV-positive people just before death by limiting the analysis to people who died at their center during 2013-2017. They also aimed to see whether rates differed by cause of death. From medical records they retrospectively collected relevant demographic and selected clinical characteristics.
Of the 86 people with HIV who died during 2013-2017, 36 (42%) had an advance directive and 64 (74%) had a formal or informal MPOA. People who completed an advance directive tended to be older (average 54.4 versus 50.5 years, P = 0.065), to have lower CD4 counts, and to make more clinical visits in the year before death (22% versus 10% with 6 or more visits). People with versus without advance directives did not differ by gender or race.
Cause of death did tend to differ in people with versus without an advance directive (AD): AIDS-related cause (31% with AD versus 22% without AD), non-AIDS cause (61% with AD versus 50% without AD), and unknown cause (8% with AD versus 28% without AD) (P = 0.075). Among people who died of non-AIDS causes, those with an advance directive had a higher cancer death rate (73% versus 32%, P < 0.001).
People with an MPOA were nonsignificantly older than those without an MPOA (average 52.6 versus 50.5 years, P = 0.37) and included a significantly higher proportion of Hispanics (16% versus 5%, P = 0.04).
MPOA rates differed significantly by cause of death: AIDS-related cause (33% with MPOA versus 5% without MPOA); non-AIDS cause (55% with MPOA versus 54% without MPOA), (P = 0.003). Among people who died of non-AIDS causes, the cancer death rate was significantly higher in those with an MPOA (63% versus 30%, P < 0.001).
The researchers stressed that even among people who died of non-AIDS cancer, nearly 40% did not have an advance directive or MPOA. In the cause-of-death analysis, the investigators noted that advance directive and MPOA completion rates were lowest in people with an unknown cause of death, a possible indicator of less terminal conditions. The University of Colorado team called for interventions to bolster advance directive completion by people with HIV.
References
1. Abdo M, Ressler A, MaWhinney S, Johnson S, Erlandson K. Advance directives and medical power of attorney assignment in individuals with HIV. 9th International Workshop on HIV and Aging, September 13-14, 2018, New York. Abstract 32.
2. Barocas JA, Erlandson KM, Belzer BK, Hess T, Sosman J. Advance directives among people living with HIV: room for improvement. AIDS Care. 2015;27:370-377.
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