Advance Care Planning Improves Psychological Symptoms But Not Quality of Life and Preferred End-of-Life Care of Patients With Cancer

Abstract

Background: This study was conducted to examine whether a longitudinal advance care planning (ACP) intervention facilitates concordance between the preferred and received life-sustaining treatments (LSTs) of terminally ill patients with cancer and improves quality of life (QoL), anxiety symptoms, and depressive symptoms during the dying process. Patients and Methods: Of 795 terminally ill patients with cancer from a medical center in Taiwan, 460 were recruited and randomly assigned 1:1 to the experimental and control arms. The experimental arm received an interactive ACP intervention tailored to participants’ readiness to engage in this process. The control arm received symptom management education. Group allocation was concealed, data collectors were blinded, and treatment fidelity was monitored. Outcome measures included 6 preferred and received LSTs, QoL, anxiety symptoms, and depressive symptoms. Intervention effectiveness was evaluated by intention-to-treat analysis. Results: Participants providing data had died through December 2017. The 2 study arms did not differ significantly in concordance between the 6 preferred and received LSTs examined (odds ratios, 0.966 [95% CI, 0.653–1.428] and 1.107 [95% CI, 0.690–1.775]). Participants who received the ACP intervention had significantly fewer anxiety symptoms (β, −0.583; 95% CI, −0.977 to −0.189; P= .004) and depressive symptoms (β, −0.533; 95% CI, −1.036 to −0.030; P= .038) compared with those in the control arm, but QoL did not differ. Conclusions: Our ACP intervention facilitated participants’ psychological adjustment to the end-of-life (EoL) care decision-making process, but neither improved QoL nor facilitated EoL care honoring their wishes. The inability of our intervention to improve concordance may have been due to the family power to override patients’ wishes in deeply Confucian doctrine–influenced societies such as Taiwan. Nevertheless, our findings reassure healthcare professionals that such an ACP intervention does not harm but improves the psychological well-being of terminally ill patients with cancer, thereby encouraging physicians to discuss EoL care preferences with patients and involve family caregivers in EoL care decision-making to eventually lead to patient value–concordant EoL cancer care.

Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review

“…Video‐only interventions varied in length from 3 to 20 minutes, 94,95 and some included accompanying questions 96 . Some depicted medical situations, such as simulated resuscitation, 94 health trajectories of long‐term care residents, 97 and specific dementia, heart failure, and other serious illness content 64,98‐100 …”

Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness

“…Between-arm baseline characteristics, accurate PA, DNR order issued, and LST preferences were balanced at randomization. 37 Data collectors were blinded to arm assignment. No research staff were involved in clinical care.…”

“…Detailed information has been reported previously about the study design, sample size calculation, participant recruitment, treatments for each arm, treatment fidelity assurance, and assessments. 37 The RCT study protocol (supplemental eAppendix 1) was approved by the ethics committee of the study site and registered at ClinicalTrials.gov (ClinicalTrials.gov identifier: NCT01912846). All participants provided written informed consent before enrollment.…”

“…Finally, time proximity to death for the DNR order was examined in only 1 RCT. 35 We therefore analyzed 1 secondary outcome of a blinded RCT of our individualized, theory-based, interactive ACP intervention 37 in facilitating accurate PA among Taiwanese patients with advanced cancer in order to improve issuing a DNR order before death. We hypothesized that tailoring our intervention to participants' readiness for prognostic information and ACP to enhance physician-patient prognostic/EoL care discussions would increase participants' likelihood of accurate PA, allowing them sufficient time to consider their EoL care goals and prepare, emotionally and practically, for EoL care decision-making to issue a DNR order earlier before patients in the control arm.…”

“…Our ACP intervention was shown to decrease the psychologic symptoms of patients with advanced cancer, facilitate accurate PA 61 to 150 days before death, and reduce receipt of CPR in their last month, but it did not improve their quality of life, help them achieve their EoL care preferences, or reduce the receipt of intensive care unit care and mechanical ventilation in their last month. 37,38 Patients and Methods…”