The Effect of Advance Care Planning on the Relationship between Health-Related Social Needs and Fear of Death

Background and Purpose: Heightened fear of death among older adults is associated with negative mental health conditions, e.g., anxiety and depression, and accelerated mortality risk. For decades, aging centered organizations have emphasized the connection between health-related social needs (HRSNs) and death-related fears. The purpose of this study is twofold: (a) a closer examination of the relationships between HRSNs and fear of death; and (b) whether advance care planning (ACP) provides a moderating effect on the aforesaid relationships. Based on principles of terror management theory, we hypothesized that death-salient discussions involved in ACP would amplify any positive relationship between HRSNs and fear of death.

Methods: We examined two waves of secondary data, years 2020 (N1) and 2022 (N2), from the national Health and Retirement Study, focusing on community dwelling older adults ages 65+ (N1=2736, N2=2859). HRSNs relating to food, housing, and transportation were measured with single yes/no items. HRSNs relating to utilities and safety were measured with single, 5- and 7-point Likert response items, respectively. Two ACP variables — ACP-related family discussion and living will possession — were measured with single yes/no items. The outcome variable, fear of death, was measured with a 5-point Likert item asking the prior week’s frequency of feeling said fear. Ordered logistic regression examined direct bivariate relationships. For each HRSN relationship with fear of death outcome, ACP moderation was tested using ordered logit interaction regression models. Odds ratios with confidence intervals among the direct and moderating/interaction effects were noted.

Results: Both samples included majority female, white, married older adults with average age of 75. Looking at N1 data, utilities was the lone HRSN with a significant direct effect on fear of death (OR=1.479; CI=1.207, 1.814; p<0.001). ACP-related family discussion linked significantly with fear of death (OR=0.601; CI=0.394, 0.919; p<0.05). ACP-related family discussion significantly moderated the positive effect of housing needs on the fear of the death outcome (OR=2.890; CI=1.226, 6.810; p<0.05). Living will possession significantly moderated the positive effect of transportation needs on fear of death (OR=0.290; CI=0.110, 0.762; p<0.05).

Looking at N2 data, three HRSNs had a significant direct effect on fear of death: housing (OR=1.631; CI=1.192, 2.232; p<0.01); utilities (OR=1.303; CI=1.132, 1.500; p<0.001); and safety (OR=0.883; CI=0.823, 0.948; p<0.01). Living will possession had a direct effect on fear of death (OR=0.694; CI=0.479, 1.006; p=0.05). With 2022 data, neither ACP variable significantly moderated the positive effects of HRSNs on fear of death.

Conclusion and Implications: From the N1 wave, ACP-related family discussion strengthened housing needs’ heightening effect on fear of death. Similarly, living will possession strengthened transportation needs’ effect on fear of death. Social work promotes ACP as a method of upholding person-centered care and reducing burden on clients and their families. These findings give implications for social workers to consider the possible compounding factors of both HRSNs and end-of-life planning with older adults, and to adjust those discussions to incorporate support and anxiety-reducing interventions for those who experience fear of death.