Advance Care Planning Can Lower Odds of Aggressive End-of-Life Treatment
June 1, 2023 4 minutes read
Patients with cancer who had engaged in advance care planning were more likely to receive comfort-based care at the end of life and were less likely to receive “aggressive” interventions aimed at prolonging life (e.g., mechanical ventilation), according to a group of researchers.1 “Recent concerns have been raised in the research community about the value of advance care planning in healthcare delivery,” observes Kristin Levoy, PhD, MSN, RN, OCN, CNE, the study’s lead author.
Levoy and colleagues set out to test the effect of advance care planning on end-of-life patients with cancer. The researchers conducted a meta-analysis of 21 studies involving 33,541 cancer patients and advance care planning. “This type of study allows us to take findings from published research on this topic and rerun those findings as a collective whole. This type of statistical synthesis allows us to make some stronger conclusions about the effect of advance care planning than an isolated study can,” explains Levoy, research scientist at Indiana University Center for Aging Research at Regenstrief Institute.
Advance care planning was associated with significantly lower odds of indicators of aggressive end-of-life care (i.e., hospital death, hospital admissions, intensive care, delayed hospice referrals, and chemotherapy). Cancer patients who engaged in advance care planning were 50% more likely to complete Do Not Resuscitate orders compared to cancer patients without an advance directive.
Investigators conducted some additional analysis to learn more about the nature of advance care planning. Studies that focused on the communication aspects of advance care planning conferred greater benefits for patients at the end of life vs. studies that emphasized the documentation components of advance care planning (e.g., learning whether a patient had created an advance directive). “This finding underscores the importance of the larger process of communication that surrounds advance care planning, rather than limiting it to a transactional process of paperwork completion,” Levoy offers.
For providers, it is important to engage in advance care planning conversations with patients and their caregivers, and to document those preferences in an advance directive. “Such efforts help make plain patients’ desires for care so that they can be honored at the end of life. This is an ethical imperative, to be sure we are honoring the patient’s autonomy,” Levoy adds.
Oncology nurses providing primary palliative care resulted in more cancer patients engaging in advance care planning, according to another group of researchers.2 “We know that specialty palliative care is helpful and guideline-recommended for patients with advanced cancer. But workforce shortages mean palliative care specialists can only see a small fraction of the patients who need their services,” says Yael Schenker, MD, MAS, FAAHPM, one of the study authors.
The study was a secondary analysis of a larger study in which investigators tested an oncology nurse-led primary palliative care intervention in outpatient oncology clinics.3 “We wanted to test whether a new, innovative palliative care intervention led by existing oncology infusion room nurses could meet patients’ needs,” says Schenker, professor of medicine and director of the Palliative Research Center at the University of Pittsburgh.
Half of the 672 patients enrolled in the study were in an intervention arm. Those patients received monthly visits by nurses with special training in primary palliative care. Experts in palliative care provided three days of in-person training to the nurses. The education covered symptom assessment and management, emotional support, advance care planning, and care coordination. The other patients received standard oncology care according to best practices, including all supportive measures deemed appropriate by the oncology team.
After three months, researchers evaluated whether patients had engaged in an end-of-life conversation with an oncologist and whether patients completed an advance directive. Of the patients who lacked an end-of-life conversation at baseline, 45% in the intervention arm had completed one at three months vs. 14.8% in the standard care arm. Of patients who lacked an advance directive at baseline, 43.2% of patients in the intervention arm had completed an advance directive vs. 18% of the standard care arm.
Even with targeted training, the oncology nurses initially found the end-of-life conversations difficult. “But clearly, they rose to the challenge and were able to have a major impact on this important aspect of patient care,” says Schenker, associate director of research education, training, and career development at the UPMC Hillman Cancer Center.
One nurse stated, “I think it kind of opens your eyes. To have those [goals of care] conversations a little sooner ... it’s not something I was comfortable with before. And it’s definitely getting a lot easier.”
“We have an ethical imperative, as healthcare providers to identify ways to incorporate these important conversations about what matters most to patients as part of routine clinical care,” Schenker stresses.
REFERENCES
1. Levoy K, Sullivan SS, Chittams J, et al. Don’t throw the baby out with the bathwater: Meta-analysis of advance care planning and end-of-life cancer care. J Pain Symptom Manage 2023; Feb 9: S0885-3924(23)00061-1. doi: 10.1016/j.jpainsymman.2023.02.003. [Online ahead of print].
2. Cohen MG, Althouse AD, Arnold RM, et al. Primary palliative care improves uptake of advance care planning among patients with advanced cancers. J Natl Compr Canc Netw 2023;21:383-390.
3. Schenker Y, Althouse AD, Rosenzweig M, et al. Effect of an oncology nurse-led primary palliative care intervention on patients with advanced cancer: The CONNECT cluster randomized clinical trial. JAMA Intern Med 2021;181:1451-1460.
Advance care planning was associated with significantly lower odds of indicators of aggressive end-of-life care (i.e., hospital death, hospital admissions, intensive care, delayed hospice referrals, and chemotherapy). Cancer patients who engaged in advance care planning were 50% more likely to complete Do Not Resuscitate orders compared to cancer patients without an advance directive.
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