Forward- or Backward-Looking? Longitudinal Evidence on Expectations, Age, and End-of-Life Planning

Background/Objectives

Subjective Survival Probabilities (SSP) capture individuals’ expectations about their remaining lifespan and may influence health-related decision-making beyond chronological age and objective health indicators. As populations age and the end-of-life (EOL) period lengthens, proactive EOL planning (such as advance directives and appointing healthcare proxies) becomes increasingly important for ensuring autonomy and aligning care with personal preferences. This study examines whether changes in SSP are associated with engagement in EOL planning among older adults in Switzerland.

Methods

We use longitudinal data from 1,040 respondents aged 50+ in the Swiss SHARE survey (waves 6 [2015] and 8 [2019/2020]). Changes in SSP are categorized as positive, negative, or no change between waves. EOL planning is measured through discussions of preferences, proxy appointment, and advance directive completion. We estimate multivariate models to assess associations between SSP changes and subsequent planning behaviours, controlling for baseline age, socio-economic, and health characteristics.

Results

Decreases in SSP are significantly associated with advance directive completion and proxy appointment. Between waves, 267 participants completed an AD, 304 appointed a proxy, and 241 discussed EOL wishes. No significant associations are observed for discussions. The association persists after adjustment for health changes and socio-demographic factors.

Conclusions

Subjective expectations about longevity are associated with formal end-of-life planning, independently of observable health status. Changes in perceived survival may represent critical moments for initiating structured advance care planning. Public health strategies should account for subjective perceptions when promoting timely and effective engagement in advance directives. This also supports public health approaches that emphasize early engagement with end-of-life planning beyond clinical settings.

Key messages

• Changes in Subjective Survival Expectations influence advance directive completion and healthcare proxy appointment, highlighting the role of subjective expectations in end-of-life planning.

• Understanding moments when individuals revise survival expectations could improve uptake of advance directives and strengthen public health approaches to end-of-life planning.