Part of an ongoing data series grounded in real advance care planning data from Koda patients.

At Koda, two of the most important things we track are who patients choose as their medical decision-maker and whether that person is actually prepared to step into that role when the time comes.

Those may sound like administrative details. They’re not.

They’re the foundation of goal-concordant care. When patients identify the right person, communicate their wishes clearly, and make sure that person understands them, the healthcare system is far more likely to honor what they actually want during serious illness or crisis.

So we pay close attention to this data.

And sometimes, it surprises us.

The split we didn’t expect

We expected some differences in how men and women identify the people closest to them.

We didn’t expect the divide to look this clear.

When patients complete advance care planning through Koda and identify who they trust most to help make medical decisions, men and women look remarkably similar across most relationship categories like siblings, friends, extended family.

Then you get to spouses and children, and the pattern almost completely flips.

Women name their children as primary decision-maker 55% of the time. Men do so just 27% of the time.

Men name their spouse 50% of the time. Women name their spouse only 22% of the time.

What’s striking is that the overall weight is almost identical: roughly 77% of both men and women choose either a spouse or a child. The difference is who they choose.

And that has real implications in practice.

In many clinical settings, there’s still an implicit “spouse-first” assumption. But our data suggests that assumption may work for only about half of male patients, and miss the mark for the majority of female patients.

During a health crisis, that’s not a small detail.

How age changes the picture

The aggregate numbers only tell part of the story. Age reshapes the data in important ways.

For women, the likelihood of naming a child as decision-maker increases steadily over time, reaching roughly 84% by age 90 and older. Some of that is likely demographic reality: many women simply outlive their spouses.

Men show a similar shift, but it happens later and more gradually. Men continue naming spouses at much higher rates well into older age.

For women, children become the dominant choice around age 50, decades before most people think of themselves as entering their final chapter. For men, that transition happens much later, if it happens at all.

The contrast is especially visible in the 60-64 age group. Women in that cohort choose their spouse only about 22% of the time, while men do so at roughly double the rate.

These are patients in similar stages of life, often facing many of the same medical realities, making fundamentally different decisions about who they trust to speak for them.

Among younger patients under 35, siblings and extended family are much more common selections, likely reflecting life stage more than preference. Most people in that age group haven’t yet built the family structures that tend to anchor later-life decision-making.

Friends consistently represent a small share across all age groups, though younger women select friends slightly more often than younger men.

One finding that didn’t vary much by gender or age: end-of-life care preferences themselves.

Preferences around things like home versus hospital care differed by only one to two percentage points between groups. The major differences weren’t in what people wanted. They were in who they trusted to help make sure those wishes were honored.

The bigger question for healthcare

The most important insight from this data isn’t really the percentages.

It’s the question underneath them.

How often are care teams contacting a spouse simply because that’s the default assumption, and not because it’s who the patient actually named?

How often is the person a patient trusts most not in the room because no one thought to include them?

Advance care planning, done well, answers those questions before a crisis makes them urgent.

It helps ensure the right person has the right information before anyone is forced to make a difficult decision in real time.

The data tells us something important: patients often know exactly who they trust.

The healthcare system just has to ask and, more importantly, listen.