Advance care planning produces trend toward less aggressive and more comfort-focused care for patients with cancer

A meta-analysis of studies involving 33,541 cancer patients evaluates the relationship between advance care planning and aggressive vs. comfort-focused end-of-life care. The study, led by Kristin Levoy, Ph.D., MSN, RN, of the Regenstrief Institute and Indiana University School of Nursing, found a general trend toward less aggressive and more comfort-focused end-of-life care among cancer patients who had engaged in advance care planning, compared to those who did not do so.

Advance care planning is a dynamic process to help prepare people for future decision-making with the goal of ensuring that individuals receive care at the end-of-life that is consistent with their preferences. Rather than a simple process of providing forms to be filled out and never reviewed, the research team noted the importance of the communication that takes place as a part the ongoing approach to advance care planning across disease trajectories.

"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," said Dr. Levoy.

"You could think of advance care planning as similar to having car insurance," she added. "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 healthcare preferences would be if you were to lose decision-making capacity and were unable to speak for yourself. The intention is that any healthcare we deliver should be patient-centered, that is, guided by the patient's' preferences and goals and consistent with their values."

Cancer often is characterized by a protracted chronic illness with fairly high levels of functioning and a steep decline in capabilities and increase in symptoms in the last six months of life. Patients generally have time to prepare for the end-of-life and can do so in the form of advance care planning to later inform decisions.

"Advance care planning works in this illness population," Dr. Levoy noted. "We found it positively impacted the decision of patients and caregivers facing cancer to avoid hospital and intensive care unit admissions and to complete do not resuscitate orders at the end-of-life. So, it worked. Compiling findings from studies involving tens of thousands of patients with cancer allows us to understand the value that advance care planning provides for patients and caregivers across the disease trajectory."

Cancer patients who engaged in advance care planning were 50 percent more likely to complete do not resuscitate orders than those who did not.

The meta-analysis found advance care planning also was associated with significantly lower odds of various indicators of "aggressive" end-of-life:

• chemotherapy
• intensive care
• hospital admissions
• delayed hospice referrals
• hospital death

The meta-analysis revealed the following outcomes were not impacted by advance care planning:

• hospice use
• cardiopulmonary resuscitation
• emergency department admissions
• mechanical ventilation

End of life preferences are highly individualized. The study authors note that evidence suggests that persons with serious illnesses generally prefer comfort-focused care and desire to avoid aggressive interventions.

"This meta-analysis is important because it provides clear evidence that advance care planning helps patients with cancer receive goal concordant care," said Regenstrief Institute Interim President and Chief Executive Officer Susan Hickman, Ph.D., a study co-author and an expert on advance care planning.

"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."

The work is published in the Journal of Pain and Symptom Management.