Examining Associations Between Legal Frameworks for Medical Planning and Intensity of End-of-Life Care

Abstract This study aims to understand the correlation between the legal framework around planning for medical treatment and the intensity of care received at the end of life. Advance directives (AD) allow an individual to legally document their wishes for medical treatment and end-of-life care, and durable powers of attorney (DPOA) allow them to identify an individual to make medical decisions on their behalf in the event they are no longer able. These laws vary greatly across time, place, and in their complexity. We estimated fixed effects model, which controls for time-invariant and state-specific factors affecting end-of-life care. Our primary outcome variable is the number of inpatient hospital days during the last six months of life, sourced from the Dartmouth Atlas Project. Our explanatory variables are hand-collected state-level legal statutes including whether the state (a) has default surrogate laws, (b) recognizes the ability to create a DPOA and/or AD, (c) permits oral directives, (d) authorizes a combined AD/DPOA, and (e) provides an official registry for ADs. Preliminary findings show recognizing DPOA and AD are negatively correlated with our outcome variable (-2.6 days; Std err 0.272) as are having default surrogate laws (-0.36 days; std err 0.157). However, allowing oral directives had an opposite effect (-.46 days; std err 0.157). Neither authorized combined AD/DPOAs nor AD registries resulted with significant correlations. These findings indicate that the existence of a basic framework such as default surrogate laws and a law governing ADs are key policy features correlated with reduced intensity in end-of-life care.

Older adults, particularly those from low-income communities, are disproportionately negatively affected by natural disasters. As the older adult population grows and natural disasters increase in frequency and intensity, social workers must consider their role in supporting the needs and safety of this population. Social workers practice in varied roles including policy advocate, service broker, and educator, all of which are crucial in disaster management. This systematic review summarizes the literature on the social work profession's involvement with emergency management with older adults, and identifies gaps. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, authors searched AgeLine, CINAHL Complete, MEDLINE, PsycINFO, and Social Work Abstracts for peer-reviewed publications between January 1, 2009 and March 1, 2020. Examples of the terms searched include social work*, respon*, prepar*, disaster, crisis, emergency, geriatrics and older adults. The initial searches yielded 298 publications. After removing duplicates and screening articles for relevance based on titles and abstracts, 21 publications were retained for full review. A total of 11 articles met inclusion criteria. The body of literature identified was small. The majority of the publications constituted conceptual papers, textbook reviews, and letters to editors requesting greater emphasis on emergency management. Only three empirical studies were identified. Broadly, the publications discussed: (1) policies and resources; (2) needs; (3) capacity across practice settings; and (4) interventions. Findings reveal an underdeveloped area of social work practice, and highlight opportunities for researchers and practitioners to define gerontological social workers' role in emergency management and detail best practice guidelines.

THE INTERPLAY OF SENIORITY AND SUPERIORITY TOWARD PERCEIVED EMPLOYABILITY OF OLDER WORKERS THROUGH A CULTURAL LENS
Clio Y.M. Cheng, and Vivian Lou, The University of Hong Kong, Hong Kong, China Background: Hong Kong will become a super-aged society comprising more than 21% of its citizens aged 65 or above by 2024. With longer life expectancy and better health conditions of the elderly, the mentality of embracing "hidden gems" -older workers was under the spotlight. Extended working life provided a golden chance for employers and/ or human resources (HR) personnel to manage this demographic change. Sau Po Centre on Ageing was commissioned to initiate a study in 2017 to 2018 on how employers and/ or HR personnel perceived employability of older workers in Hong Kong, and to consolidate good practices of elderfriendly employment. Methods: Aiming to garner opinions from a wide variety of employers and/or HR personnel, 33 in-depth interviews were conducted with participants from various industries and company sizes, including both large corporations and small and medium enterprises (SMEs). Among the participants, nearly half (n=15) possessed managerial position, other including employers (n=1), directors (n=6), officers (n=8) and others (n=3). Among these companies, 19 did not have any mandatory retirement age policies, while seven had their retirement age set as 60 years old, and another seven set their retirement age at aged 65. Results: Participants tended to link seniority, in terms of both chronological age and loyalty, with superiority, affecting their perceived employability of older workers. This study has multi-level implications on a multi-generational ageinclusive workforce management strategy on recruitment, retainment and retraining. Suggestions on good practices of an age-inclusive and age-diverse workforce were also made at individual, corporation and societal level. Assisted living (AL) communities are increasingly home to frail, chronically ill older adults who remain until death. State laws mandate that AL facilities request copies of any advance care planning documents residents have and make forms available upon request. Using secondary data from a larger study funded by the National Institute on Aging (R01AG047408) that focuses on end-of-life (EOL) care in AL, this project investigated barriers and facilitators to conducting advance care planning in AL. Data included in-depth interviews (of 86 minute average length) with 20 administrators from 7 facilities around the Atlanta metropolitan area and aggregate data collected from each facility regarding facility, staff, and resident characteristics. Findings from thematic analysis of qualitative data showed that key barriers to planning in AL included lack of staff training and reluctance among administrators and families to discuss advance care planning and EOL care. Important facilitators included periodic follow-up discussions of residents' wishes, often during care plan meetings, educating families about the importance of planning, and external support for staff training and family education from agencies such as hospice and home health. Three study facilities exceeded state requirements to request and store documents by systematically encouraging residents to complete documentation. These facilities, whose administrators discuss advance care planning and residents' EOL wishes with residents and families during regular care plan meetings, were more likely to have planning documents on file, demonstrating the potential of long-term care communities, such as AL, to successfully promote advance care planning among residents and their family members.

ASSISTED LIVING ADMINISTRATORS' APPROACHES TO ADVANCE CARE PLANNING
for medical treatment and end-of-life care, and durable powers of attorney (DPOA) allow them to identify an individual to make medical decisions on their behalf in the event they are no longer able. These laws vary greatly across time, place, and in their complexity. We estimated fixed effects model, which controls for time-invariant and state-specific factors affecting end-of-life care. Our primary outcome variable is the number of inpatient hospital days during the last six months of life, sourced from the Dartmouth Atlas Project. Our explanatory variables are hand-collected state-level legal statutes including whether the state (a) has default surrogate laws, (b) recognizes the ability to create a DPOA and/or AD, (c) permits oral directives, (d) authorizes a combined AD/DPOA, and (e) provides an official registry for ADs. Preliminary findings show recognizing DPOA and AD are negatively correlated with our outcome variable (-2.6 days; Std err 0.272) as are having default surrogate laws (-0.36 days; std err 0.157). However, allowing oral directives had an opposite effect (-.46 days; std err 0.157). Neither authorized combined AD/DPOAs nor AD registries resulted with significant correlations. These findings indicate that the existence of a basic framework such as default surrogate laws and a law governing ADs are key policy features correlated with reduced intensity in end-of-life care.

EXPERIENCES OF LGBT PATIENTS AND FAMILIES WITH HOSPICE AND PALLIATIVE CARE: PERSPECTIVES OF THE PALLIATIVE CARE TEAM
Cathy Berkman, 1 and Gary Stein, 2 1. Fordham University,New York,New York,United States,2. Yeshiva University,New York,New York,United States The lesbian, gay, bisexual, and transgender (LGBT) community experiences discrimination and stigma in accessing health care and social services -including palliative, hospice, and long-term care. Healthcare providers not recognize or address disparities in care. Providers and institutions may be uncomfortable with sexual orientation and gender identity and expression issues, and often don't inquire about these.
LGBT patients fear being open about their identities, not receiving equal or safe treatment, and having their family of choice and designated surrogates disrespected or ignored by healthcare staff. This study examines the degree to which hospice and palliative care providers report inadequate, disrespectful, or abusive care to LGBT patients and family members. A cross-sectional study using an online survey was completed by 865 providers, including social workers, physicians, nurses, and chaplains. Among respondents, 55% reported that LGB patients were more likely than non-LGB patients to experience discrimination at their institution; 24% observed discriminatory care; 65% reported that transgender patients were more likely than non-transgender patients to experience discrimination; 20% observed discrimination to transgender patients; 14% observed the spouse/partner of LGBT patients having their treatment decisions disregarded or minimized; and 13% observed the spouse/partner being treated disrespectfully. Qualitative data are presented to illustrate discomfort with LGBT patients and spouses/partners, disrespectful care, gossip and ridicule, inadequate care, and denial of care. Implications and suggestions for implementing non-discriminatory and respectful institutional and public policy, and for staff education and training to provide competent and respectiful care to this population are presented.

FAMILY CAREGIVERS' DECISION-SUPPORT NEEDS BEYOND THE DECISION AID
Katherine Britt, 1 and Karen Schlag, 2 1. The University of Texas at Austin,Austin,Texas,United States,2. University of Texas at Austin,Austin,Texas,United States Of the estimated 16 million U.S. family members currently providing essential yet unpaid caregiving for persons with dementia (PWD), many will also make end-of-life (EOL) care decisions as surrogates, a process that can be fraught with uncertainty. Even with dementia death rates rising, many families delay advanced care planning (ACP) discussions, and surrogate decision makers often lack crucial information and support, implicating the need to further study this topic in aging. While decision aids (DA) serve as a support tool for caregivers, they can be less effective when failing to address unresolved decisional needs. Utilizing the Ottawa Decision Support Framework (ODSF), which asserts caregiver decision needs affect decision quality, this study sought to identify surrogate decision-support needs extending beyond general ACP. This mixed study used cognitive interviews and focus groups with family caregivers (N=13) and healthcare professionals (n=14) to assess their knowledge and understanding of hospice and artificial hydration and nutrition. Data were audio-recorded, transcribed verbatim, and analyzed with thematic content analysis. Three main themes were identified: DAs alone aren't enough to foster quality decision making for surrogates; individualized communication is necessary to clarify PWD and caregiver value priorities and disease trajectories; and clarification of the impact of care choices within situational contexts is quintessential. Further development is needed to create a practice protocol from these themes to inform professionals assisting surrogates in ACP at EOL. Practical implications from this study include highlighting the importance of individualized communication between PWD, providers, and caregivers in addressing EOL care decisional needs.

IDENTIFYING GAPS IN KNOWLEDGE AND BARRIERS TO UTILIZATION OF HOSPICE AND END-OF-LIFE CARE SERVICES
Lenard Kaye, Nicholas Silver, Carli Hutchison, and David Wihry, University of Maine, Bangor, Maine, United States Hospice and end-of-life (HEOL) services have traditionally been underutilized, especially in rural areas. A community assessment, performed in eastern Maine, sheds light on the extent to which public and health care professional attitudes and knowledge explain HEOL service access and utilization levels. Structured surveys were distributed in the fall of 2019 targeting community residents (18 years and older) and hospice/health care professionals. Residents (n=213) displayed significant levels of ignorance concerning the purpose and availability of HEOL services. Although a range of HEOL services were rated as highly important, residents were unable to confirm their actual availability. Overall, one in every two residents did not know if particular HEOL services existed locally (ranging from a low of 27% that were unsure whether grief support services were available to 67% unaware of the presence of a community hospice house). Hospice/health professionals (n=22) were aligned in their belief that the public did not have a clear understanding of the intent of HEOL services. Interestingly, community residents lacked equivalent measures