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Prevalence of Advance Directives in the United...

Prevalence of Advance Directives in the United States: A Systematic Review and Meta-analysis


Advance directives are the primary tool for people to use in communicating their wishes for end-of-life care in the event of incapacity. However, data regarding the completion of advance directives in the United States are inconsistent and of variable quality. We systematically searched six databases (PubMed, Embase, CINAHL, Scopus, Web of Science, and ProQuest) and reviewed refereed studies published between 2011 to 2016 to determine the proportion of U.S. adults with a completed advance directive, including a living will and/or health care power of attorney. Our primary outcome of "any advance directive" was categorized into "living will," "health care power of attorney," and "advance directive-undefined." The latter category included studies that reported a combined completion rate for living wills and health care powers of attorney or did not specify the type of advance directive. When more than one category was reported without mutual exclusivity, we included the largest proportion in our computation of “any advance directive,” acknowledging that either a living will or a health care power of attorney is considered an advance directive. Owing to the heterogeneity across studies, we conducted random-effects meta-analyses to determine the overall completion proportions for all four outcomes as well as “any advance directive” completion proportions by subgroups.


  • Otto Haas Charitable Trust

Study Status


Results & Impact

Among the 795,909 Americans from the 150 included studies, we found that 36.7 percent had completed some advance directive. Only 29.3 percent had completed a living will that contains actual care wishes, and 33.4 percent had designated a health care power of attorney. Completion rates were nominally higher among patients (38.2 percent) than among healthy adults (32.7 percent) and significantly higher among patients ages 65 and older (45.6 percent) than among younger adults (31.6 percent). For patients with chronic disease, advance directive completion was highest among those with neurologic disease (56.5 percent) and lowest among those with HIV/AIDS (17.3 percent). Overall, our results suggest that prevalence of advance directives has been low and stagnant across recent years. We offer several strategies to increase completion rates, which include incorporating patients’ values and goals into these documents and simplifying inconsistent legal barriers to completion. As advance directives remain an essential element of high-quality advance care planning, future efforts to motivate their completion should target populations with low prevalence rates and at high risk of critical illness and death.


Yadav KN, Gabler NB, Cooney E, Kent S, Kim J, Herbst N, et al. Approximately one in three US adults completes any type of advance directive for end-of-life care. Health Aff (Millwood). 2017;36(7).

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