Introduction: Dementia leads to progressive cognitive decline, impairing self-care and decision making. Advance directives (AdvDirs) enable individuals to document healthcare preferences while cognitively capable, ensuring value-aligned care and reducing caregiver burden. This study explores factors influencing preferences for unlimited medical treatment in hypothetical Alzheimer’s disease/dementia scenarios among community-dwelling adults. Methods: This cross-sectional study surveyed 163 community-dwelling adults (18+), using structured questionnaires to collect sociodemographic, health, and AdvDir-related data. Key predictors included attitudes toward life-sustaining treatments, comfort discussing death, religious practices, and interest in quality-of-life information related to end-of-life care. The primary outcome was preference for unlimited medical treatment in hypothetical dementia scenarios. Bivariate and multivariate logistic analyses assessed associations, adjusting for covariates. Results: In the dementia scenario, 26.9% of participants preferred unlimited medical treatment. This preference was strongly associated with a pre-existing attitude favoring life-sustaining treatments (OR = 4.24, 95% CI: 1.73 – 10.37, P = 0.002) and religious beliefs (OR = 5.68, 95% CI: 1.51–21.43, P = 0.01). Conversely, an interest in learning about quality of life at the end of life was negatively associated with preferring unlimited treatment (OR = 0.29, 95% CI: 0.09-0.89, P = 0.03). Discussion: Our findings highlight the need to align advance care planning with individuals’ values, beliefs, and religious practices. Raising awareness of quality-of-life considerations in end-of-life care may lead to a shift in preference toward palliative care rather than aggressive treatment. Healthcare providers should discuss treatment trade-offs with cultural and religious sensitivity to support informed decision making.
BloomDECanningDLubetA. Global population aging: facts, challenges, solutions & perspectives. Daedalus. 2015;144(2):80-92. https://www.jstor.org/stable/24711220. Accessed 29 January 2025.
2.
BoylePAYuLLeurgansSE, et al.Attributable risk of Alzheimer’s dementia attributed to age-related neuropathologies. Ann Neurol. 2019;85(1):114-124. doi:10.1002/ana.25380
BloomDELucaDL. Chapter 1 - the global demography of aging: facts, explanations, future. In: PiggottJWoodlandA, eds. Handbook of the Economics of Population Aging. Amsterdam: North-Holland; 2016, 1, 3-56. doi:10.1016/bs.hespa.2016.06.002
6.
HarperS. Economic and social implications of aging societies. Science. 2014;346(6209):587-591. doi:10.1126/science.1254405
HickmanRLPintoMD. Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill. J Clin Nurs. 2014;23(5-6):756-765. doi:10.1111/jocn.12427
15.
SediniCBiottoMCrespi Bel’skijLMMoroni GrandiniRECesariM. Advance care planning and advance directives: an overview of the main critical issues. Aging Clin Exp Res. 2022;34(2):325-330. doi:10.1007/s40520-021-02001-y
16.
FleurenNDeplaMFIAJanssenDJAHuismanMHertoghCMPM. Underlying goals of advance care planning (ACP): a qualitative analysis of the literature. BMC Palliat Care. 2020;19(1):27. doi:10.1186/s12904-020-0535-1
17.
HarrisonKLAdrionERRitchieCSSudoreRLSmithAK. Low completion and disparities in advance care planning activities among older medicare beneficiaries. JAMA Intern Med. 2016;176(12):1872-1875. doi:10.1001/jamainternmed.2016.6751
18.
McMahanRDHickmanSESudoreRL. What clinicians and researchers should know about the evolving field of advance care planning: a narrative review. J Gen Intern Med. 2024;39(4):652-660. doi:10.1007/s11606-023-08579-5
19.
WolffJLScerpellaDGiovannettiER, et al.Advance care planning, end-of-life preferences, and burdensome care: a pragmatic cluster randomized clinical trial. JAMA Intern Med. 2025;185:e246215. doi:10.1001/jamainternmed.2024.6215, Published online December 2, 2024.
20.
PorteriC. Advance directives as a tool to respect patients’ values and preferences: discussion on the case of Alzheimer’s disease. BMC Med Ethics. 2018;19(1):9. doi:10.1186/s12910-018-0249-6
21.
GasterBLarsonEBCurtisJR. Advance directives for dementia: meeting a unique challenge. JAMA. 2017;318(22):2175-2176. doi:10.1001/jama.2017.16473
22.
KavalieratosDErnecoffNCKeim-MalpassJDegenholtzHB. Knowledge, attitudes, and preferences of healthy young adults regarding advance care planning: a focus group study of university students in Pittsburgh, USA. BMC Public Health. 2015;15(1):197. doi:10.1186/s12889-015-1575-y
23.
KarelMJMoyeJBankAAzarAR. Three methods of assessing values for advance care planning. J Aging Health. 2007;19(1):123-151. doi:10.1177/0898264306296394
24.
HegdeSEllajosyulaR. Capacity issues and decision-making in dementia. Ann Indian Acad Neurol. 2016;19(Suppl 1):S34-S39. doi:10.4103/0972-2327.192890
25.
RodriguezKLYoungAJ. Perceptions of patients on the utility or futility of end‐of‐life treatment. J Med Ethics. 2006;32(8):444-449. doi:10.1136/jme.2005.014118
26.
SeamarkDASeamarkCJHalpinDMG. Palliative care in chronic obstructive pulmonary disease: a review for clinicians. J R Soc Med. 2007;100(5):225-233.
27.
OwusuaaCvan LentLGGvan ‘t SpijkerAvan der RijtCCDvan der HeideA. Discussing prognosis and the end of life with patients with advanced cancer or COPD: a qualitative study. PLoS One. 2022;17(9):e0274201. doi:10.1371/journal.pone.0274201
