The public's perspectives on advance directives: Implications for state legislative and regulatory policy

Objectives: Determine the prevalence of advance directives (ADs) in Maryland and identify the barriers and enablers to their adoption, in order to guide the formulation of state legislative policy. Methods: Cross-sectional survey administered over the telephone to a representative age-stratified random sample of 1195 Maryland adults. Results: Approximately 34% (n= 401) of Maryland adults reported having an AD. Older adults (65+ years) were more likely than younger adults (18-64 years) to have ADs (p< 0.001); the proportional difference between those with and without ADs diminished as age increased. Two times as many Whites than Blacks reported having ADs (43-23%; p< 0.001). Of those who had an AD, the primary motivations for creating one was a personal medical condition or a diagnosis to one's self or a family/friend (41%). Those without ADs identified lack of familiarity with them (27%), being too young or healthy to need one (14%), or uncertainty of the process for adopting one (11%) as reasons for not having one. Conclusions: Barriers to AD adoption appear amenable to policy interventions. Policies that seek to increase access and ensure ease of enrollment, combined with a targeted public health advocacy campaign, may help increase the prevalence of ADs.