An Examination of Factors Influencing the Likelihood of Having an Advance Directive

Due to the lack of questions about end-of-life issues on major ongoing national surveys, little is known about how attitudes and behaviors toward end-of-life matters differ across the US population. From a health policy standpoint, advance directives (ADs) and factors influencing the likelihood of having an AD are of particular interest, since prior studies have shown that individuals with ADs were associated with significantly lower levels of Medicare spending and a lower likelihood of hospital deaths.

A recent nationally representative survey of 7,946 individuals 18 years and better aimed to examine which US adults are more and less likely to have an AD, and to determine what factors are associated with the completion of an AD. These researchers looked at demographic factors and education, income, and employment status, as well as how the presence of a chronic condition, having a regular source of health care, and concerns or discussions about end-of-life impacted the likelihood of having an AD.

Overall, 26 percent of individuals surveyed had an AD. When those individuals without an AD were asked why they did not have one, the most common response was a lack of awareness.

The survey found that completing an AD was associated with older age, more education, and higher income. While less than 30 percent of individuals under 65 years old had ADs, 51 percent of those over 65 had them. Single individuals were the least likely to have ADs, with only 15 percent having them, while 27 percent each of both married and divorced individuals were more likely to have an AD. Most likely to have an AD were individuals who were widowed, with 47 percent.

While only 21 percent of individuals with an annual income under $25,000 had ADs, close to 25 percent of individuals earning between $25,000 and $75,000 had them, and 32 percent of individuals making more than $75,000. Thirty-three percent of individuals who reported having a chronic disease had an AD, compared to only 22 percent of those without a chronic condition. Individuals who had a regular source of health care were also more likely to have an AD. While 28 percent of individuals with a regular source of care had ADs, only 13 percent of those without regular care had them.

Non-white individuals were less likely to have ADs, even when they had comparable levels of education to the white study participants. Compared to the 30 percent of white participants, only 17 percent of African Americans and Hispanics had ADs. Among those individuals who reported having had a discussion about end-of-life, 44 percent had an AD, compared to only 9 percent of those who had not had an end-of-life discussion. This suggests that while having an end-of-life discussion increases the likelihood of having an AD, simply having a discussion is often not sufficient, since less than 50 percent of those who have had such discussions have an AD. Advance directives were also less frequent among individuals who reported not knowing if they had end-of-life concerns.

In light of the small percentage of individuals with ADs and the public health benefits associated with having one, ADs are a topic that needs more attention. In particular, individuals need to be made better aware of ADs and the benefits that they can provide. Additionally, further research is needed to examine whether cultural factors play a role in the lower adoption of ADs among nonwhite populations, so that interventions can be designed to overcome these. If the Affordable Care Act leads to greater regular access to health care, this could potentially lead to a greater adoption of ADs. However, overall the percentages of individuals without ADs remain quite low, even for those with regular access to medical care and for older adults.


Rao JK, Anderson LA, Feng-Chang L, et al. Completion of advance directives among U.S. consumers. American Journal of Preventative Medicine 2014; 46(1): 65–70.

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