Advance care planning among older Canadians amid the COVID-19 pandemic: a focus on sexual orientation

Abstract

Objectives: The COVID-19 pandemic has led to death and hardship around the world, and increased popular discourse about end-of-life circumstances and conditions. The extent to which this discourse and related pandemic experiences have precipitated advance care planning (ACP) activities was the focus of this study with a particular emphasis on sexual orientation. Methods: A large, national online survey was conducted between 10 August and 10 October 2020 in Canada. The final sample of 3923 persons aged 55 and older was recruited using social media, direct email, and Facebook advertising and in conjunction with community groups. Women comprised almost 78% of the sample; just more than 7% of the sample identified as lesbian, gay, and bisexual (LGB). Measures included demographic variables and a series of questions on ACP, including documents and discussions undertaken prior to the pandemic and since its onset. Results: Descriptive analyses revealed few gender or sexual orientation differences on documents and discussions prior to the pandemic; since its onset, LGB persons have completed or initiated wills, powers of attorney, advance directives, representation agreements, and have engaged in ACP discussions in greater proportion than heterosexuals. Logistic regressions reveal the increased likelihood of pre-pandemic ACP engagement by age, gender (women), and education; since the pandemic onset, gender, education, and sexual orientation were predictive of greater ACP engagement. Care discussions were more likely undertaken by women and LGB persons since the pandemic most often with spouses, family, and friends, especially among LGB persons. Discussion: Gender roles and previous pandemic experiences (HIV/AIDS, in particular) are implicated in this pattern of results; opportunities for educational interventions are considered.

An Agentic Familiarity: The Context of HIV/AIDS and Sexual Orientation for Older Canadians during the COVID-19 Pandemic

“…These results have implications beyond how LGBT persons, and especially GB men, adhere to public health mandates and approach the COVID-19 pandemic. de Vries et al [31], for example, make inferences to these same phenomena in their analyses of Advance Care Planning (ACP) among older LGBT persons, drawing from the same sample as the present study. They found that since the onset of the COVID-19 pandemic, LGBT persons were 1.6 times more likely than were cisgender heterosexual persons of comparable age to have begun or completed at least one of the following: a will, durable power of attorney, Advance Directives, and/or a Representation Agreement.…”

Situation, Education, Innovation, and Recommendation: A Large-Scale Systematic Review of Advance Care Planning in the Age of COVID-19

“…Some studies noted a need for adequate ACP training for clinicians as a barrier [ 76 , 91 , 142 ]. Moreover, the findings of our review indicate that certain communities experienced or were vulnerable to a lack of engagement in ACP due to a combination of factors; disparities in health education [ 90 ], cultural and religious beliefs [ 57 , 86 , 90 , 142 ], socioeconomic challenges [ 57 , 140 ], a general distrust in the healthcare system [ 65 , 124 , 125 , 137 ], and racial or ethnic barriers [ 53 , 90 , 124 , 140 ] played significant roles. These factors were compounded by the pandemic’s exacerbation of healthcare access disparities.…”

“…Similar to the education and resources offered to healthcare professionals, public-facing ACP education and resources for patients and family members were also identified as facilitators for ACP [ 64 , 65 , 66 , 69 , 72 , 80 ]. The increased availability of resources and education for patients and families has been vital in facilitating ACP.…”

Barriers to LGBTQIA-Inclusive Palliative Care

“…Evidence shows mixed results regarding the likelihood of successful completion of ACP between LGBTQIA individuals and their heterosexual counterparts. Some studies show an increased rate of ACP completion 14,15 especially if the individuals lived in states that did not legally recognize same-sex relationships 16 while other studies show reduced rates due to fear of discrimination. 17 This allows patients’ wishes to be respected and minimizes the chances of their loved ones experiencing disenfranchised grief, which is when an individual feels isolated in their grieving because their grief is not typically recognized by society at large.…”