Tremendous improvements in medical technology have helped save lives from disease and accidents and enabled people with chronic and complex conditions to live longer. However, advanced medical care has also resulted in the unintended consequence of prolonging deaths. This means people receive “futile care” to keep them alive for days, weeks, or even months beyond what was expected [12]. Morbidity and mortality are high in old age, but End-Of-Life (EOL) care has become increasingly complicated owing to advances in medical technology. Therefore, many adults and their family caregivers face more difficult medical decisions over the course of serious and chronic illness at the EOL [12].

The definition of withholding Life-Sustaining Treatments (LSTs) is “a decision not to start or increase a life-sustaining intervention (p. 1164)”[3]. LSTs should generally be withheld or withdrawn after obtaining the consent of patients, their loved ones (i.e., spouses, children, and relatives/friends), and health care proxies if there is no hope of recovery or if terminally ill patients do not want to prolong their lives [4]. In a study, prior to hospitalization, only 11.9% of patients preferred to receive LSTs [5]. In a study by Winter and colleagues, the majority of residents (88%) wanted their physician to withhold or withdraw LSTs, while 9% wanted to receive them [6].

Many factors can be related to the decision regarding LSTs at the EOL. Those factors include patients' or families' preferences; the religious and cultural beliefs of health care providers, patients, and families; race/ethnicity; and socioeconomic factors [78910]. Patient factors demonstrated to be associated with withholding LSTs are old age, female gender, being Caucasian, poor functional status, and comorbidities [1011].

In the United States, the percentage of hospital deaths decreased from 32.6% in 2000 to 19.8% in 2015, whereas the percentage of admissions to the Intensive Care Unit (ICU) in the last month of life increased from 24.3% in 2000 to 29% in 2015 [12]. Bereaved family members reported that receiving LSTs and dying in hospital were not consistent with the decedent's preferences and did not contribute to the quality of dying in older adults [131415]. Therefore, there has been an increase in public attention toward advance care planning, which includes a living will, Durable Power Of Attorney (DPOA), and EOL discussion as key determinants of EOL decision making, especially in the case of people for whom a decision regarding LSTs needs to be made [514]. However, there is limited information on advance care planning and other factors related to the decision regarding LSTs in adults who die in hospital in the United States.

Even though there is a growing interest in the decision regarding LSTs to prevent futile care in hospitals, little is known about the factors associated with the decision to withhold LSTs in adults who die in hospital. In this study, the prevalence of the decision to withhold LSTs was approximately 61%, which was higher than in previous studies. Quill and colleagues reported that 11.7% of patients in the United States made the decision to forgo LSTs prior to ICU discharge or death [10]. Another study, which was conducted in Norway, found that a quarter of patients had a decision to limit their LSTs during their ICU stays [11]. Such differences in prevalence between previous studies and the current study may result from differences in the characteristics of the study populations. The present study population was composed of deceased middle-aged and older adults (average age: 78.5), whereas previous studies collected data at the time of ICU admission in patients who were alive [1011], and had younger study populations (average age: 58.8) [11].

A study examining the prevalence of withholding LSTs in 177 patients who died in an emergency department in Morocco reported that LSTs were withheld by 24.2% of patients [18], which was still lower than that of the present study. This may be because the patients who died in emergency department were in life-or-death situations and younger than the patients who generally die in hospital. In a study examining the Physician Orders for Life-Sustaining Treatment (POLST), a type of advance care planning, in nursing facilities [19], among residents who completed the POLST form, 85.7% signed the Do-Not-Resuscitate (DNR) order and 98% of residents who had a DNR form received the care they wanted before their deaths. Further studies comparing different medical settings with regard to the decision related to specific types of LSTs among middleaged and older adults are needed.

The findings of the present study showed that race, religion, having a private insurance policy, having a living will, and having discussed EOL care were significant factors associated with the decision to withhold LSTs. African Americans had 49.7% lower odds of making the decision to withhold LSTs as compared to Caucasians, which was consistent with the findings that ethnic-minority groups had 27~35% lower odds of making the decision to withhold LSTs in the ICU [10]. Racial differences in decision making at the EOL may be affected by socioeconomic status, religious and cultural background, and health care utilization [20]. A study that interviewed Caucasians and African Americans aged 55 or older in the United States found that African Americans expressed feelings of mistrust toward physicians, whereas Caucasians preferred to have EOL dis cussions with physicians. Also, African Americans believed that the completion of a living will may result in withholding of LSTs even if they wanted to receive them [21]. Further studies are needed to better understand the culture regarding EOL decision making based on racial differences. For example, in East Asian countries, such as South Korea, Japan, and Taiwan, the traditional cultural perspective toward death and dying is influenced by Confucianism and Buddhism. Asians in these countries tend to show reluctance to take part in EOL discussions with others and are more focused on the role of the main decision-maker, such as the oldest son and daughter [722]. Therefore, to promote discussions about advance care planning and LSTs, racial differences must be taken into consideration.

Being Catholic was negatively associated with the decision to withhold LSTs, which was consistent with a previous finding that in the United States, fundamentalist Catholics were significantly more likely than non-Catholics to desire LSTs [23]. Catholic patients may believe that only God knows when it is the right time to die and may consider making the decision to withhold LSTs at their EOL inconsistent with their religious beliefs [20]. However, a study in the European Union reported that physicians who were Catholic were more likely to withhold LSTs compared to those who belonged to other religions [24], which indicated that health care providers' religious affiliation is also important in the decision to withhold LSTs. Therefore, the religious affiliations of everyone involved, including patients, family members, and health care providers, should be simultaneously considered in future investigations regarding decision making about LSTs at the EOL.

Having a private insurance policy was positively associated with the decision to withhold LSTs. In this study, net worth, Medicaid, and having a private insurance policy were highly correlated (r>.70); therefore, the investigator considered having a private insurance policy a factor representing participants' socioeconomic status. In the United States, having private health insurance means that people can afford to meet their physicians and nurse practitioners, enabling them to have the necessary discussions about their EOL care and complete a living will about their preferences for LSTs [132526]. Most Americans make the decision to withhold/withdraw LSTs at the EOL only after discussing the issue with health care providers [182526].

Having a living will was a significant factor associated with the decision to withhold LSTs. This living will described the patient's preferences about the decision regarding LSTs and helped family members and health care providers make a decision if the patient lacked the capacity to do so [21419]. Having discussed EOL care was also a very important factor in decision making regarding LSTs in this study. EOL discussions between patients, family members, and health care providers can prevent confusion, conflicts, delayed decision making, and futile care at the EOL [1427] and help patients receive EOL care consistent with their preferences [131828].

In the United States, the Patient Self-Determination Act (PSDA) passed in 1990 required health care providers in hospitals, nursing homes, and health care facilities to ask about the presence of advance directives and to include patients' preferences in medical records. The PSDA promoted the use of advance directives in health care facilities, which led to an increase in the completion of advance directives [29], but there was still a lack of awareness and support from health care providers [30]. Therefore, since 2016, the Centers for Medicare and Medicaid Services have begun providing reimbursements for EOL discussions regarding advance care planning with physicians [31]. Health care providers and policymakers expect that this health insurance coverage will make it easier for older Americans to have discussions about their EOL care with health care providers and to complete advance directives, which will ultimately lead to a decrease in receiving unwanted LSTs before death.

Various programs and community groups, such as “Five Wishes,” “Respecting Choices Various programs and community groups, such as “Five Wishes,” “Respecting Choices Program,” and “The End-of-Life Nursing Education Consortium” in the United States seek to involve people in EOL discussions and encourage them to document their wishes in advance directives, such as the living will and POLST. Also, the use of structured communication tools regarding EOL decision making could promote the discussion about advance care planning and the completion of a living will and help people receive the care they desire, as documented in their advance directives [32]. Mass media (e.g., television programs and radio) and EOL-related websites could shed light on various cases involving EOL decisions, helping increase public interest in decisions regarding LSTs in patients' last days, months, and years [33].

This study had several limitations. First, this study could not control for other factors that may be related to EOL decision making, such as family-related factors, severity of illness, types of LSTs, and health care system (e.g., staffing, type of hospital, and hospital policies regarding EOL care), and which might influence the decision to withhold LSTs [71011]. Second, this study relied on proxy reports after middle-aged and older adults' death, which may be biased owing to memory limitations (“recall bias”) and the tendency of proxies to answer in ways they deem to be socially acceptable (“social desirability bias”). Third, there was the measurement issue because most variables related to EOL care were dichotomized to yes or no answers. Especially, advance care planning includes various forms, such as living wills and POLST, and LSTs include various treatments, such as cardiopulmonary resuscitation, ventilator care, endotracheal intubation, chemotherapy, dialysis, feeding tube, and use of antibiotics [41419]. Therefore, the findings of this study cannot be generalized to all aspects of EOL decision making. Last, the findings of this study cannot be generalized to middle-aged and older adults who die in nursing homes, hospice, or their own homes.

Using data from a nationally representative sample in the United States, this study examined the factors associated with the decision to withhold LSTs in Americans aged 50 or above who died in hospital. The findings of the present study suggest that differences in race and religious affiliation should be considered when middle-aged and older adults, family members, and health care providers make decisions regarding LSTs at the EOL. Also, health insurance coverage for discussions about advance care planning makes it easier for people to discuss LSTs with health care providers.