The Impact of Advance Care Planning on End-of-Life Care: Do the Type and Timing Make a Difference for Patients With Advanced Cancer Referred to Hospice?

Abstract

Purpose: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician. Methods: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life. Results: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001). Conclusions: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.

End‐of‐Life Practice Patterns in Head and Neck Cancer

“…In patients with advanced cancer, one study has shown that ACP documentation was associated with fewer admissions in the final 30 days of life. 10 Only 53.8% of patients in our cohort had some form of advanced care documents which suggests an opportunity for improved documentation.…”

Living with Metastatic Cancer: A Roadmap for Future Research

“…Providers may hesitate to initiate ACP discussions due to concern about causing distress; however, a large prospective study of patients with advanced cancer and family caregivers found that end-of-life discussions with medical providers were not associated with increased risk of depression or worry [182]. In fact, discussions between patients and providers regarding goals of care were associated with fewer hospital admissions and less aggressive treatment near end-of-life [183,184], which may improve quality of life and reduce financial toxicity [185]. Bereaved family members also have better psychological adjustment when patients undergo less aggressive treatments near end-of-life [182].…”

“…Bereaved family members also have better psychological adjustment when patients undergo less aggressive treatments near end-of-life [182]. The majority of research on ACP involves hospitalized patients and those near end-of-life [183][184][185][186]; however, goals of care can be an ongoing and evolving discussion throughout metavivorship. Further research is needed to determine the optimal timing of ACP discussions for metavivors and their family caregivers.…”

The impact of initial treatment strategy and survival time on quality of end-of-life care among patients with oesophageal and gastric cancer: A population-based cohort study

“…Previous research has shown that advanced care planning is an important factor for quality of EOL care in terms of decreasing in-hospital death and increasing hospice referral [51]. However, Prater et al demonstrated that advanced care planning at an early stage (�30 days before death) was more strongly associated with quality care outcomes compared to planning that occurred near death [52]. The availability and readiness of current health care services might not be sufficient to meet the quality standard for place of death when time is scarce.…”