Accurate prognostic awareness and preference states influence the concordance between terminally ill cancer patients’ states of preferred and received life-sustaining treatments in the last 6 months of life

Abstract

Background: Factors facilitating/hindering concordance between preferred and received life-sustaining treatments may be distorted if preferences and predictors are measured long before death. Aim: To examine factors facilitating/hindering concordance between cancer patients’ preferred and received life-sustaining-treatment states in their last 6 months. Design: Longitudinal, observational design. Setting/participants: States of preferred and received life-sustaining treatments (cardio-pulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, and nasogastric tube feeding) were examined in 218 Taiwanese cancer patients by a latent transition model with hidden Markov modeling. Multivariate logistic regression modeling was used to examine factors facilitating/hindering concordance between preferred and received life-sustaining-treatment states. Results: Concordance between preferred and received life-sustaining-treatment states was poor (40.8%, kappa value (95% confidence interval): 0.05 [–0.03, 0.14]). Patients who accurately understood their prognosis and preferred comfort care were significantly more likely to receive preferred life-sustaining treatments before death than those who did not know their prognosis but wanted to know, those who were uniformly uncertain about what life-sustaining treatments they preferred to receive, and those who preferred nutritional support but declined other life-sustaining treatments. Patient age, physician–patient end-of-life-care discussions, symptom distress, and functional dependence were not associated with concordance between preferred and received life-sustaining-treatment states. Conclusion: Prognostic awareness and preferred states of life-sustaining treatments were significantly associated with concordance between preferred and received life-sustaining-treatment states. Personalized interventions should be developed to cultivate terminally ill cancer patients’ accurate prognostic awareness, allowing them to formulate realistic life-sustaining-treatment preferences and facilitating their receiving value-concordant end-of-life care.

Factors associated with prognostic awareness in patients with cancer: A systematic review

“…On the other hand, this review also found associations of accurate PA with positive aspects such as better communication with family and health care providers, 14 feeling of having control 32 and inner peace 35 . Recent longitudinal studies showed that prognostic discussion can help in building therapeutic alliance 78 and patients with accurate prognostic awareness are more likely get the treatment which they prefer 67 . One potential solution for this dilemma of potential negative aspects of prognostic disclosure might be in tailoring communication about prognosis according to patients' preferences rather than focus on achieving accurate prognostic awareness itself while hoping that this will ease patients' suffering.…”

“…Accurate PA was also associated with less utilization of intravenous chemotherapy, 17,62 intubation, and mechanical ventilation 59 . Patients with accurate prognostic awareness received often preferred type of care 67 . On the other hand, patients with accurate PA tend to have shorter survival than patients with inaccurate PA 17, 23, 24, 26, 39, 44 .…”

Prognostic awareness in advanced cancer patients and their caregivers: A longitudinal cohort study

“…At the same time, the available evidence shows that most patients prefer to be informed about their diagnosis and prognosis, even if it is poor, and their preferences for health information are not related to their level of prognostic awareness 10–12 . Several studies also showed that accurate prognostic awareness can positively influence achieving goal‐concordant care at the end of life 13–15 . Although we could expect some specific factors being associated with prognostic awareness of patients in the Eastern Europe, recent systematic reviews did not find any research published on prognostic awareness from this region 6,7,9 …”

Preference for Aggressive End-of-Life Care among Advanced Cancer Patients in Wuhan, China: A Cross-Sectional Study

“…Cancer patients who recognized that they were terminally ill preferred symptom-directed EOL care over life-extending therapy [ 6 , 42 ]. Due to the low prevalence of cancer patients’ prognostic disclosure, it is critical to promote rational communication between physicians and patients regarding accurate disclosure of prognosis to help patient make appropriate LST preferences [ 43 ].…”