Is Annual Income a Predictor of Completion of Advance Directives (ADs) in Patients With Cancer

Fahad Saeed, Guibo Xing, Daniel J. Tancredi, Ronald M. Epstein, Kevin A. Fiscella, Sally A. Norton, Paul R. Duberstein

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Context: Completion of advance directives (ADs) enhances the likelihood of receiving goal-concordant treatments near the end of life. Previous research on community samples have shown that completion of ADs is less common in lower socioeconomic status demographic group; there is a paucity of such research in patients with cancer. Objectives: To study the effect of income and education on the completion of ADs. Hypothesis: Patients with cancer having lower incomes and education levels would be less likely to report completing ADs. Methods: We conducted cross-sectional analyses of data provided by patients (n = 265) enrolled in the Values and Options in Cancer Care clinical trial. Patients with advanced cancer reported whether they had (1) completed a living will or (2) designated a health-care proxy. Response options for both questions were yes (scored 1), no (scored 0), and unsure (scored 0). We studied the association of lower household income (≤US$20 000) and education level (never attended college) with AD scores. Results: Patients with lower annual incomes had lower AD scores (estimate −0.44; confidence intervals [CI]: −0.71 to −0.16, P =.001); the association between higher educational attainment (some college or more) and completion of ADs was not statistically significant (estimate 0.04, CI: −0.16 to 0.24, P =.70). Conclusion: Interventions to promote completion of ADs among lower income patients with serious illnesses are needed.

Original languageEnglish (US)
Pages (from-to)402-407
Number of pages6
JournalAmerican Journal of Hospice and Palliative Medicine
Issue number5
StatePublished - May 1 2019

All Science Journal Classification (ASJC) codes

  • Medicine(all)


  • advance directives
  • education
  • end-of-life care
  • low income
  • socioeconomic disparities


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