{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T20:18:14Z","timestamp":1784146694295,"version":"3.55.0"},"reference-count":31,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2025,12,19]],"date-time":"2025-12-19T00:00:00Z","timestamp":1766102400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/"}],"funder":[{"DOI":"10.13039\/100000027","name":"National Institute on Alcohol Abuse and Alcoholism","doi-asserted-by":"publisher","award":["P01-AA029545"],"award-info":[{"award-number":["P01-AA029545"]}],"id":[{"id":"10.13039\/100000027","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000027","name":"National Institute on Alcohol Abuse and Alcoholism","doi-asserted-by":"publisher","award":["U01-AA026224"],"award-info":[{"award-number":["U01-AA026224"]}],"id":[{"id":"10.13039\/100000027","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000027","name":"National Institute on Alcohol Abuse and Alcoholism","doi-asserted-by":"publisher","award":["U10-AA013566"],"award-info":[{"award-number":["U10-AA013566"]}],"id":[{"id":"10.13039\/100000027","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000027","name":"National Institute on Alcohol Abuse and Alcoholism","doi-asserted-by":"publisher","award":["U24 AA020794"],"award-info":[{"award-number":["U24 AA020794"]}],"id":[{"id":"10.13039\/100000027","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000738","name":"U.S. Department of Veterans Affairs","doi-asserted-by":"publisher","award":["SDR 02-237"],"award-info":[{"award-number":["SDR 02-237"]}],"id":[{"id":"10.13039\/100000738","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000738","name":"U.S. Department of Veterans Affairs","doi-asserted-by":"publisher","award":["98-004"],"award-info":[{"award-number":["98-004"]}],"id":[{"id":"10.13039\/100000738","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>An advance directive (AD) document allows a patient to indicate their health care preferences and identify an agent to make decisions on their behalf if they lose their ability to communicate. Due to the substantially elevated risk of acute respiratory failure and death during the COVID-19 pandemic, ADs were especially relevant. The objective of this study was to describe AD completed prior to COVID-19 infection (COVID-19) among patients receiving care in a national healthcare system.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a cohort study of United States Veterans Health Administration (VA) patients with COVID-19 between March 2020 and December 2022. AD completion before COVID-19 was ascertained by progress note titles in the electronic health record. Covariates included age, sex, race\/ethnicity, marital status, geographic region, health care utilization, calendar quarter of COVID-19, and VA COVID-19 (VACO) 30-day mortality index score.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 422,028 COVID-19 patients (median age\u2009=\u200962 years; 88.5% male; 58.6% non-Hispanic White (NH-White), 23.3% non-Hispanic Black (NH-Black), 9.2% Hispanic), 67,970 (16.1%) had AD documentation which varied substantially across all covariates. AD completion increased with VACO Index quintiles ranging from 8.2 to 31.0%. In a model adjusted for covariates, relative to NH-White, NH-Black and Hispanic groups had decreased odds for AD (NH-Black odds ratio (OR)=0.77 (95% confidence interval 0.76\u20130.79); Hispanic OR=0.85 (0.82\u20130.87)).<\/jats:p>\n                    <jats:p>VACO index includes age, and both were strongly associated with AD completion. Women compared to men, and those who were widowed, separated\/divorced and never married relative to people who were married, had increased AD completion.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>AD completion was overall low, including among patients at high risk of mortality due to COVID-19. When controlling for age, risk for mortality and other covariates, men and people who identify as Black or Hispanic were less likely to have completed an AD. Investment in interventions to facilitate AD completion are needed, particularly among historically underrepresented populations.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0338825","type":"journal-article","created":{"date-parts":[[2025,12,19]],"date-time":"2025-12-19T18:39:15Z","timestamp":1766169555000},"page":"e0338825","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Advance directives prior to COVID-19 diagnosis in a United States national healthcare system"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9614-1179","authenticated-orcid":true,"given":"Amy R.","family":"Schwartz","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janet P.","family":"Tate","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lisa Soleymani","family":"Lehmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2823-9649","authenticated-orcid":true,"given":"Joseph T.","family":"King","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristie M.","family":"Walenczyk","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Woody","family":"Levin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shelli L.","family":"Feder","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy C.","family":"Justice","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathleen M.","family":"Akg\u00fcn","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,12,19]]},"reference":[{"issue":"7","key":"pone.0338825.ref001","doi-asserted-by":"crossref","first-page":"1244","DOI":"10.1377\/hlthaff.2017.0175","article-title":"Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care","volume":"36","author":"KN Yadav","year":"2017","journal-title":"Health Aff (Millwood)"},{"issue":"13","key":"pone.0338825.ref002","doi-asserted-by":"crossref","first-page":"1211","DOI":"10.1056\/NEJMsa0907901","article-title":"Advance directives and outcomes of surrogate decision making before death","volume":"362","author":"MJ Silveira","year":"2010","journal-title":"N Engl J Med"},{"key":"pone.0338825.ref003","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.c1345","article-title":"The impact of advance care planning on end of life care in elderly patients: randomised controlled trial","volume":"340","author":"KM Detering","year":"2010","journal-title":"BMJ"},{"issue":"1","key":"pone.0338825.ref004","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1111\/jgs.16801","article-title":"Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review","volume":"69","author":"RD McMahan","year":"2021","journal-title":"J Am Geriatr Soc"},{"issue":"12","key":"pone.0338825.ref005","doi-asserted-by":"crossref","first-page":"1872","DOI":"10.1001\/jamainternmed.2016.6751","article-title":"Low Completion and Disparities in Advance Care Planning Activities Among Older Medicare Beneficiaries","volume":"176","author":"KL Harrison","year":"2016","journal-title":"JAMA Intern Med"},{"issue":"11","key":"pone.0338825.ref006","doi-asserted-by":"crossref","first-page":"2620","DOI":"10.1111\/jgs.16730","article-title":"Regional Variation in Billed Advance Care Planning Visits","volume":"68","author":"LE Skolarus","year":"2020","journal-title":"J American Geriatrics Society"},{"issue":"6","key":"pone.0338825.ref007","doi-asserted-by":"crossref","first-page":"1352","DOI":"10.1111\/jgs.14800","article-title":"Ethnic Differences in Advance Directive Completion and Care Preferences: What Has Changed in a Decade?","volume":"65","author":"J Portanova","year":"2017","journal-title":"J Am Geriatr Soc"},{"issue":"6","key":"pone.0338825.ref008","doi-asserted-by":"crossref","first-page":"688","DOI":"10.1177\/1049909120966585","article-title":"Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature","volume":"38","author":"M Bazargan","year":"2021","journal-title":"Am J Hosp Palliat Care"},{"key":"pone.0338825.ref009","doi-asserted-by":"crossref","first-page":"100331","DOI":"10.1016\/j.ssmph.2018.100331","article-title":"Racial and ethnic differences in end-of-life care in the United States: Evidence from the Health and Retirement Study (HRS)","volume":"7","author":"M Orlovic","year":"2018","journal-title":"SSM Popul Health"},{"issue":"2","key":"pone.0338825.ref010","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1111\/jgs.15656","article-title":"Predictors of Advance Care Planning in Older Women: The Nurses\u2019 Health Study","volume":"67","author":"JH Kang","year":"2019","journal-title":"J Am Geriatr Soc"},{"issue":"8","key":"pone.0338825.ref011","doi-asserted-by":"crossref","first-page":"1078","DOI":"10.1089\/jpm.2017.0374","article-title":"Racial and Ethnic Differences in Advance Care Planning: Results of a Statewide Population-Based Survey","volume":"21","author":"MA Clark","year":"2018","journal-title":"J Palliat Med"},{"issue":"1","key":"pone.0338825.ref012","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1177\/00031348211011115","article-title":"Insurance Status and Ethnicity Impact Health Disparities in Rates of Advance Directives in Trauma","volume":"89","author":"KL Haines","year":"2023","journal-title":"Am Surg"},{"key":"pone.0338825.ref013","volume-title":"VHA Handbook 1004.02. 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United States, May-August 2020","volume":"69","author":"JAW Gold","year":"2020","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"pone.0338825.ref024","article-title":"The struggle for health equity: the sustained effort by the VA Healthcare System","author":"SA Ibrahim","year":"2014","journal-title":"Am J Public Health"},{"issue":"1","key":"pone.0338825.ref025","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1089\/heq.2018.0086","article-title":"Racial\/Ethnic Disparities in Mortality Across the Veterans Health Administration","volume":"3","author":"MS Wong","year":"2019","journal-title":"Health Equity"},{"issue":"3","key":"pone.0338825.ref026","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1016\/j.jpainsymman.2018.05.016","article-title":"Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons","volume":"56","author":"G Jimenez","year":"2018","journal-title":"Journal of Pain and Symptom Management"},{"issue":"3","key":"pone.0338825.ref027","doi-asserted-by":"crossref","DOI":"10.1016\/j.jpainsymman.2021.04.025","article-title":"Advance Care Planning, Palliative Care, and End-of-life Care Interventions for Racial and Ethnic Underrepresented Groups: A Systematic Review","volume":"62","author":"T Jones","year":"2021","journal-title":"J Pain Symptom Manage"},{"issue":"7","key":"pone.0338825.ref028","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1089\/jpm.2020.0272","article-title":"Advance Directives\/Care Planning: Clear, Simple, and Wrong","volume":"23","author":"R Sean Morrison","year":"2020","journal-title":"Journal of Palliative Medicine"},{"issue":"3","key":"pone.0338825.ref029","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1089\/jpm.2022.0016","article-title":"Caught in a Loop with Advance Care Planning and Advance Directives: How to Move Forward?","volume":"25","author":"VS Periyakoil","year":"2022","journal-title":"J Palliat Med"},{"issue":"10","key":"pone.0338825.ref030","doi-asserted-by":"crossref","first-page":"3006","DOI":"10.1111\/jgs.18000","article-title":"Giving up on the objective of providing goal-concordant care: Advance care planning for improving caregiver outcomes","volume":"70","author":"TR Fried","year":"2022","journal-title":"J Am Geriatr Soc"},{"key":"pone.0338825.ref031","volume-title":"Survey of Veteran Enrollees\u2019 Health and Use of Health Care","author":"Trilogy Federal LLC","year":"2023"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0338825","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,19]],"date-time":"2025-12-19T18:39:23Z","timestamp":1766169563000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0338825"}},"subtitle":[],"editor":[{"given":"Sk Md Mamunur Rahman","family":"Malik","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,12,19]]},"references-count":31,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12,19]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0338825","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,19]]}}}