1. Comments on “Why Are White Nursing Home Residents Twice as Likely as African Americans to Have an Advance Directive? Understanding Ethnic Differences in Advance Care Planning” by Jennifer Troyer Barbara Schone

2. What Are Advance Directives “Advance directives are the legal documents, such as the living will, durable power of attorney and health care proxy, which allow people to convey their decisions about end-of-life care ahead of time. Advance directives provide a way for patients to communicate their wishes to family, friends, and health care professionals and to avoid confusion later on, should they become unable to do so.” NCI website

3. Benefits of Establishing Advance Directives Provides an opportunity for individuals to make ex ante choices about their course of treatment and end-of-life experience for the time when they might be unable to do so Provides an opportunity for individuals to make ex ante choices about their course of treatment and end-of-life experience for the time when they might be unable to do so – More Care or Less Care Potential cost savings if individuals desire lower levels of care Potential cost savings if individuals desire lower levels of care – Is there evidence of such cost saving?

4. Costs of Establishing Advanced Directives Transaction Costs Transaction Costs Difficulty of confronting the issues Difficulty of confronting the issues

5. Benefits versus Costs Net of the costs just outlined, it would appear to be efficient to establish advanced directives, even if you have especially strong tastes for care at the end of life Net of the costs just outlined, it would appear to be efficient to establish advanced directives, even if you have especially strong tastes for care at the end of life

6. Reasons that Advanced Directives Might Not Be Established Costs exceed benefits Costs exceed benefits A desire for the outcome that occurs legally when no wishes are specified A desire for the outcome that occurs legally when no wishes are specified – May vary by state – Are there ways to exploit this when looking at differences?

7. How Does This Paper Fit In? Evidence that white nursing home residents are much more likely to have advanced directives relative to African American nursing home residents Evidence that white nursing home residents are much more likely to have advanced directives relative to African American nursing home residents The goal of the paper is to determine the role of individual, facility and geographic factors in explaining the racial differences in advanced directives The goal of the paper is to determine the role of individual, facility and geographic factors in explaining the racial differences in advanced directives

8. Key Finding Individual, facility and geographic differences explain approximately half of the difference in advance directives between whites and African Americans Individual, facility and geographic differences explain approximately half of the difference in advance directives between whites and African Americans

9. General Comments Analyses and results seem straightforward Analyses and results seem straightforward It would be helpful to know more about the process used to establish advanced directives It would be helpful to know more about the process used to establish advanced directives Site of death Site of death – 53% hosp, 19% NH, 21% home, 4% other u 93 National Mortaility Followback Survey – Are most established in hospitals? – Could different patterns of hospitalization by race contribute to the differences?

10. Other Questions to Ponder Do we have to worry about differential selection by race into nursing homes? Do we have to worry about differential selection by race into nursing homes? Are these differences some evidence of “market” failure or do they reflect underlying preferences? Are these differences some evidence of “market” failure or do they reflect underlying preferences? What is the policy issue? If we uncover and explain the factors that lead to these differences, then what? What is the policy issue? If we uncover and explain the factors that lead to these differences, then what?