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Start the most difficult conversation American isn’t having- the conversation about our end of life preferences

Millennials: An Eager Audience For Advance Care Planning

Study shows desire for doctors to be direct 


People under 40 want hospital staff to bring up end of life-related issues and help them complete advance directives.

If clinicians hope to get more young adults to consider and document their health care preferences, they’re going to have to work harder.

A survey of health care professionals and patients identifies key approaches to reaching this underserved and elusive population.

People under 40 want hospital staff to bring up end of life-related issues and help them complete advance directives. They appreciate simple and direct answers to their questions, and they prefer that clinicians hand materials to them directly.

These findings are published in the newly released “Conversation Starters: Research Insights from Clinicians and Patients on Conversations About End-of-Life Care and Wishes,” a study commissioned by the John A. Hartford Foundation, the California Health Care Foundation and Cambia Health Foundation. Younger people may also be more open to community-based initiatives.

“Far too many people with serious illness are not receiving care that reflects their wishes and preferences,” said Terry Fulmer, president of the Hartford Foundation, during an online seminar about the survey.

An advance health care directive may take the form of a living will, power of attorney or the Five Wishes collection. The overall purpose of such forms is to help ensure one’s end of life wishes are carried through during emergencies or hospitalizations. Ideally, an advance directive should be a “living document” updated throughout one’s life as health and relationships change. A 25-year-old who completes an advance directive today may have far different preferences and beliefs in 2050.

However, because serious illness and incapacity may strike at anytime, the Hartford Foundation also encourages millennials – adults in their 20s through mid-30s – to have their wishes documented. Plus, the earlier one is exposed to such materials, the easier it will be to broach the topic later in life.

“Both patients and clinicians strongly agree that starting these conversations early is best,” said Marcus Escobedo, senior program officer at the Hartford Foundation. “Patients and clinicians want these conversations to become a routine part of care.”

Unfortunately, only about a quarter of American adults have completed such forms. Completion rates are much higher among seniors, whites and the wealthy.

Researchers organized six focus groups about advance care planning made up of clinicians (general practitioners, internists, oncologists, cardiologists, pulmonologists, nurse practitioners and physician assistants). A seventh focus group, composed of 31 racially diverse adults 40 and older with advance care plans, was conducted online.

“This study really was a call to action,” said Dr. Sandra Hernández, president of the California Health Care Foundation. “Conversations done earlier are largely better.”

The majority of participants said providers and patients should begin having advance care planning conversations when patients are in their 20s and 30s, partly because these conversations are much easier when people are young, healthy and cognizant. Only a handful said conversations should begin after age 45.

Clinicians also need training for minority and non-English-speaking patients, the survey found.

Researchers caution that if health care systems fail to act, many millennials will seek guidance elsewhere, from attorneys or family members. Change might begin by integrating conversation starters into formal systems to assess whether patients have an advance care plan. This could happen in a routine wellness visit or another type of visit.