Caregivers formal digital proxy roles and engagement in advance care planning: A cross-sectional study

Caregivers increasingly act as proxies, managing patients digital accounts and making complex end-of-life decisions. Greater dyadic engagement in advance care planning (ACP) improves patient and caregiver outcomes, yet empirical evidence linking formal digital proxy roles to ACP engagement remains limited. The study aims to quantify patterns of ACP engagement, digital proxy roles, and how these caregivers behaviors are associated among caregivers in Singapore. We conducted a cross-sectional survey among an online panel of nationally representative adults in Singapore to identify caregivers and assessed their lifetime engagement in formal proxy roles across legal, financial, and medical digital domains, along with ACP proxy behaviors. Formal digital proxies had institutional or joint access to digital financial accounts (for financial digital proxies) or digital patient health/caregiver accounts (for medical digital proxies). ACP engagement was measured using 13 proxy-related behaviors, such as discussing end-of-life care preferences. Multivariable regressions were performed. In total, we identified 276 caregivers, who assisted with instrumental activities daily living to another adult from 311 completed responses. Among caregivers (age 41.0{+/-}13.8, 46.2% female), 28.9% were legal proxies and 40.2% were formal digital proxies (31.5% financial; 29.0% medical). Overall engagement was modest (mean 3.97{+/-}4.54) despite most reported completing at least one behavior. Compared to non-proxies, medical (AME=3.722, 95%CI: 2.143-5.301) and financial digital proxies (AME=1.515, 95%CI: 0.121-2.910) reported significantly higher ACP engagement while legal proxy status did not. High-stakes discussions on life-sustaining treatment and health-state preferences showed low engagement. Formal digital proxy roles are positively associated with ACP engagement and may provide a strategic entry point for interventions. Persistent deficits in high-stakes ACP highlight limited readiness for complex end-of-life decisions and the need for targeted decision-support tools.