Trends in Advance Care Planning in Patients With Cancer

Abstract

Importance Advance care planning (ACP) may prevent end-of-life (EOL) care that is non-beneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether cancer patients’ participation in ACP has increased over time. Objective To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences, and to explore associations between ACP subtypes and EOL treatment intensity, as reflected in EOL care decisions and terminal hospitalizations. Design Prospectively collected survey data from the Health and Retirement Study (HRS), including data from in-depth “exit” interviews conducted with next-of-kin surrogates following the death of an HRS participant. Trends in ACP subtypes were tested, and multivariable logistic regression models examined associations between ACP subtypes and measures of treatment intensity. Setting HRS, a nationally representative, biennial, longitudinal panel study of U.S. residents over age 50. Participants 1,985 next-of-kin surrogates of HRS participants with cancer who died between 2000 and 2012. Main Outcome and Measures Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences, as well as associations between ACP subtypes and surrogate-reported EOL care decisions/terminal hospitalizations. Results From 2000-2012, there was an increase in DPOA assignment (52% to 74%, p=0.03), without change in use of living wills (49% to 40%, p=0.63) or EOL discussions (68% to 60%, p=0.62). Surrogates increasingly reported that patients received “all care possible” at EOL (7% to 58%, p=0.004), and rates of terminal hospitalizations were unchanged (29% to 27%, p=0.70). Both living wills and EOL discussions were associated with limiting/withholding treatment [living will: adjusted odds ratio (AOR)=2.51, 95% confidence interval (CI)=1.53-4.11, p<0.001; EOL discussions: AOR=1.93, 95% CI=1.53-3.14, p=0.002], while DPOA assignment was not. Conclusions and Relevance Use of DPOA increased significantly between 2000 and 2012, but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision-makers are critically needed to ensure receipt of goal-concordant care.

Contextualizing the Use of Oncologic Imaging within Treatment Phases: Imaging Trends and Modality Preferences, 2000–2014

“…We do not expect oncologists to have accurately predicted survival duration for their patients, but we assume that education and clinical experience would give the oncologists some ability to estimate long-term survival likelihood and duration. Despite the conflict between provider knowledge and ordering behaviours, our findings about imaging intensity in the final months of life are congruent with research indicating a tendency toward patients receiving "all care possible" at end of life 12 .…”

Intricate decision making: ambivalences and barriers when fulfilling an advance directive

“…Over and above that, it shows that there is a wide distribution of subjectively perceived barriers. Such barriers can only be overcome through open and honest communication within therapeutic relationships 28. A process of extensive advance care planning is recommended in this study, along with the nomination of a person with power of attorney over health issues, as alternative ways to ensure self-determination at the end of people’s lives.…”

Advance Care Planning: is quality end of life care really that simple?

“…15 As others have noted, doing more of the things that facilitate delivery of ACP (such as the creation of specialist facilitators and implementation of policy) will not reduce the effects of those things that undermine or create barriers to it. 15 As others have noted, doing more of the things that facilitate delivery of ACP (such as the creation of specialist facilitators and implementation of policy) will not reduce the effects of those things that undermine or create barriers to it.…”