Investigators have found that patients with advanced cancer who participated in advance care planning may have received less aggressive and more comfort-focused end-of-life cancer care compared with those who did not participate in advance care planning, according to a new study published by Levoy et al in the Journal of Pain and Symptom Management.
Background
Advance care planning—a dynamic process designed to prepare patients for future decision-making—aims to ensure that patients with advanced disease receive end-of-life cancer care that is consistent with their preferences. The investigators stressed that the physician-patient communication process may be more effective at ensuring the success of advance care planning across disease trajectories than a simple process of providing forms for patients to fill out.
“You could think of advance care planning as similar to having car insurance. The idea of advance care planning is that you're protecting yourself for future eventualities that may or may not occur, and you're documenting what your health-care preferences would be if you were to lose decision-making capacity and were unable to speak for yourself. The intention is that any health care we deliver should be patient-centered, that is, guided by the patients’ preferences and goals and consistent with their values,” explained lead study author Kristin Levoy, PhD, MSN, RN, OCN, CNE, Assistant Professor of Community and Health Systems at the School of Nursing and a research scientist at the Center for Aging Research at the Regenstrief Institute at the Indiana University. “Our findings demonstrated that efforts to directly engage patients and caregivers in the communication components of advance care planning were a crucial aspect of improving the end-of-life care that patients with cancer received,” she emphasized.
Cancer is often characterized as a protracted chronic illness with fairly high levels of maintained functionality, but there may be a steep decline in capabilities and increase in symptoms in the last 6 months of life. Patients generally have time to prepare for end-of-life cancer care and can do so in the form of advance care planning to later inform decisions.
Study Methods and Results
In the new study, the investigators analyzed the cases of 33,541 patients with advanced cancer to evaluate the relationship between advance care planning and aggressive vs comfort-focused end-of-life cancer care. They found that patients who engaged in advance care planning were 50% more likely to complete do-not-resuscitate orders compared with those who did not engage in advance care planning.
Additionally, advance care planning was associated with significantly lower odds of various indicators of aggressive end-of-life care—including chemotherapy, intensive care, hospital admissions, delayed hospice referrals, and hospital death. The investigators further discovered that hospice use, cardiopulmonary resuscitation, emergency department admissions, and mechanical ventilation were not impacted by advance care planning.
Conclusions
The investigators underscored that the patients with advanced cancer who were involved in the study generally preferred comfort-focused care over aggressive interventions at the end of life—although they acknowledged that end-of-life preferences are highly individualized.
“This meta-analysis is important because it provides clear evidence that advance care planning helps patients with cancer receive goal-concordant care,” suggested co–study author Susan Hickman, PhD, the Cornelius and Yvonne Pettinga Professor of Medicine at the School of Medicine as well as Interim President and Chief Executive Officer of the Regenstrief Institute at the Indiana University. “While there is still a lot of work that needs to be done to improve advance care planning implementation, our findings confirm that ongoing conversations about goals, values, and preferences are essential to help prepare patients and their caregivers for end-of-life decision-making,” she concluded.
Disclosure: For full disclosures of the study authors, visit jpsmjournal.com.
