Advance Care Planning Among Older Adults with Limited Income: Results and Recommendations from a Qualitative Study

Outcomes 1. Using a didactic and interactive learning approach, participants will self-report the ability to comprehend and apply the consideration of adverse childhood experiences when initiating advance care planning with patients, particularly those with overlapping disadvantages (e.g., low income, disability).2. Using a didactic and interactive learning approach, participants will self-report the ability to comprehend and apply the basics of trauma-informed care principles to advance care planning discussions. Key Message Older adults with low income are more likely to have adverse childhood experiences and less likely to have advance care planning (ACP) than those with high income. Qualitative findings suggest that structural, life-stage, and social stressors influence individual resilience and ACP capacity and underscore the necessity of trauma-informed ACP approaches. Introduction/Context If equitable, advance care planning (ACP) can promote patient and familial autonomy, confidence, and decision-making proficiency during health crises and reduce disparities during times of cognitive incapacity. Due to persistent inequities, older adults with low income continue to have lower rates of ACP participation and are more likely to suffer from ongoing psychological, physical, and social health challenges than those with high-income. Objectives To improve our comprehension of the contributing factors of this ACP disparity, we aimed to explore barriers and facilitators to healthcare access and ACP during three life stages (childhood, adulthood, and older adulthood). Methods Using purposive and snowball sampling, we recruited twenty older adults (50+) with limited income ( <$20,000/year) from six community locations in Nashville, Tennessee. We performed semi-structured and audio-recorded interviews in participant homes following a qualitative descriptive design. Two independent coders iteratively coded individual lines of transcript data contributing to a single, hierarchically organized codebook. Final themes emerged from the inductive analysis of repeated codes and deductive use of the Cumulative Disadvantage Theory. Results Sample characteristics included a mean age of 64.8 years old (SD: 6.8), 11 participants that identified as female (55.0%), and 16 that identified as Black or African American (80.0%). Five themes consisted of structural, life-stage, and social stressors and resources, individual stress responses and ACP readiness, and the ACP process. Conclusion Participants informed a complex conceptual understanding of the multi-faceted and cumulative nature of stressors and protective factors that contribute to individual stress responses and readiness to participate in ACP as a preventative health behavior. These initial findings provide a framework for improving short-term clinical outcomes and developing long-term community-based interventions. Using the AHRQs six dimensions of quality, we will discuss palliative practice implications, including consideration of adverse childhood experiences and trauma-informed care strategies. Keywords Shared Decision Making / Advance Care Planning / Diversity, Equity, Inclusion, Belonging, Justice