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

View More View Less
  • a School of Nursing, Medical College, Chang Gung University;
  • b Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung;
  • c Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou;
  • d Division of Hematology-Oncology, Chang Gung Memorial Hospital; and
  • e Chang Gung University College of Medicine, Tao-Yuan, Taiwan; and
  • f Department of International Business, Soochow University, and
  • g College of Nursing, National Taipei University of Nursing and Health Science, Taipei, Taiwan.
Restricted access

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.

Correspondence: Siew Tzuh Tang, DNSc, School of Nursing, Medical College, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan, Taiwan, 333, R.O.C. Email: sttang@mail.cgu.edu.tw

Supplementary Materials

    • Supplemental Material (PDF 957 KB)
  • 1.

    Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: The National Academies Press; 2014.

    • Search Google Scholar
    • Export Citation
  • 2.

    Peppercorn JM, Smith TJ, Helft PR, . Toward individualized care for patients with advanced cancer. J Clin Oncol 2011;29:755760.

  • 3.

    Johnson S, Butow P, Kerridge I, . Advance care planning for cancer patients: a systematic review of perceptions and experiences of patients, families, and healthcare providers. Psychooncology 2016;25:362386.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Rietjens JA, Sudore RL, Connolly M, . Definition and recommendations for advance care planning: an international consensus supported by the European Association for Palliative Care. Lancet Oncol 2017;18:e543551.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Sudore RL, Heyland DK, Lum HD, . Outcomes that define successful advance care planning: a Delphi panel consensus. J Pain Symptom Manage 2018;55:245255.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Heyland DK, Frank C, Groll D, . Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members. Chest 2006;130:419428.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Bekelman JE, Halpern SD, Blankart CR, . Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. JAMA 2016;315:272283.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Falchook AD, Dusetzina SB, Tian F, . Aggressive end-of-life care for metastatic cancer patients younger than age 65 years. J Natl Cancer Inst 2017;109:djx028.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Hung YN, Liu TW, Wen FH, . Escalating healthcare expenditures in cancer decedents’ last year of life: a decade of evidence from a retrospective population-based cohort study in Taiwan. Oncologist 2017;22:460469.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Wright AA, Zhang B, Ray A, . Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:16651673.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Mack JW, Weeks JC, Wright AA, . End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences. J Clin Oncol 2010;28:12031208.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Au DH, Udris EM, Engelberg RA, . A randomized trial to improve communication about end-of-life care among patients with COPD. Chest 2012;141:726735.

  • 13.

    Detering KM, Hancock AD, Reade MC, . The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010;340:c1345.

  • 14.

    Epstein RM, Duberstein PR, Fenton JJ, . Effect of a patient-centered communication intervention on oncologist-patient communication, quality of life, and health care utilization in advanced cancer: the VOICE randomized clinical trial. JAMA Oncol 2017;3:92100.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Kirchhoff KT, Hammes BJ, Kehl KA, . Effect of a disease-specific planning intervention on surrogate understanding of patient goals for future medical treatment. J Am Geriatr Soc 2010;58:12331240.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Morrison RS, Chichin E, Carter J, . The effect of a social work intervention to enhance advance care planning documentation in the nursing home. J Am Geriatr Soc 2005;53:290294.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Pearlman RA, Starks H, Cain KC, . Improvements in advance care planning in the Veterans Affairs System: results of a multifaceted intervention. Arch Intern Med 2005;165:667674.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Stein RA, Sharpe L, Bell ML, . Randomized controlled trial of structured intervention to facilitate end-of-life decision making in patients with advanced cancer. J Clin Oncol 2013;31:34033410.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Curtis JR, Downey L, Back AL, . Effect of a patient and clinician communication-priming intervention on patient-reported goals-of-care discussions between patients with serious illness and clinicians: a randomized clinical trial. JAMA Intern Med 2018;178:930940.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Cherny N. Palliative care: lemonade from lemons: exploring the results of the VOICE study. Nat Rev Clin Oncol 2017;14:810.

  • 21.

    Tang ST, Wen FH, Chang WC, . Preferences for life-sustaining treatments examined by hidden Markov modeling are mostly stable in terminally ill cancer patients’ last 6 months of life. J Pain Symptom Manage 2017;54:628636.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:3848.

  • 23.

    Tamayo-Velázquez MI, Simón-Lorda P, Villegas-Portero R, . Interventions to promote the use of advance directives: an overview of systematic reviews. Patient Educ Couns 2010;80:1020.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Cohen SR, Mount BM, Tomas JJ, . Existential well-being is an important determinant of quality of life. Evidence from the McGill Quality of Life Questionnaire. Cancer 1996;77:576586.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361370.

  • 26.

    Wasteson E, Brenne E, Higginson IJ, . Depression assessment and classification in palliative cancer patients: a systematic literature review. Palliat Med 2009;23:739753.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Elmqvist MA, Jordhøy MS, Bjordal K, . Health-related quality of life during the last three months of life in patients with advanced cancer. Support Care Cancer 2009;17:191198.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Lo C, Zimmermann C, Rydall A, . Longitudinal study of depressive symptoms in patients with metastatic gastrointestinal and lung cancer. J Clin Oncol 2010;28:30843089.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Christakis NA, Escarce JJ. Survival of Medicare patients after enrollment in hospice programs. N Engl J Med 1996;335:172178.

  • 30.

    Astrup GL, Hofso K, Bjordal K, . Patient factors and quality of life outcomes differ among four subgroups of oncology patients based on symptom occurrence. Acta Oncol 2017;56:462470.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Seow H, Barbera L, Sutradhar R, . Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J Clin Oncol 2011;29:11511158.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Rose JH, O’Toole EE, Dawson NV, . Perspectives, preferences, care practices, and outcomes among older and middle-aged patients with late-stage cancer. J Clin Oncol 2004;22:49074917.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;327:307310.

  • 34.

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159174.

  • 35.

    Hollis S, Campbell F. What is meant by intention to treat analysis? Survey of published randomised controlled trials. BMJ 1999;319:670674.

  • 36.

    Tate RL, Pituch KA. Multivariate hierarchical linear modeling in randomized field experiments. J Experimental Educ 2007;75:317337.

  • 37.

    Liu TW, Wen FH, Wang CH, . Terminally ill Taiwanese cancer patients’ and family caregivers’ agreement on patterns of life-sustaining treatment preferences is poor to fair and declines over a decade: results from two independent cross-sectional studies. J Pain Symptom Manage 2017;54:3545.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38.

    Yang Y. A family-oriented Confucian approach to advance directives in end-of-life decision making for incompetent elderly patients. In: Fan RP, ed. Family-Oriented Informed Consent: East Asian and American Perspectives. Basel, Switzerland: Springer International Publishing; 2015:257–270.

    • Crossref
    • Export Citation
  • 39.

    Campbell DT. Factors relevant to the validity of experiments in social settings. Psychol Bull 1957;54:297312.

  • 40.

    Bernacki RE, Block SD. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med 2014;174:19942003.

  • 41.

    Fakhri S, Engelberg RA, Downey L, . Factors affecting patients’ preferences for and actual discussions about end-of-life care. J Pain Symptom Manage 2016;52:386394.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Basch E, Deal AM, Kris MG, . Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. J Clin Oncol 2016;34:557565.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Haun MW, Estel S, Rücker G, . Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 2017;12:CD011129.

  • 44.

    Fried T, Zenoni M, Iannone L. A dyadic perspective on engagement in advance care planning. J Am Geriatr Soc 2017;65:172178.

  • 45.

    Barnato AE. Challenges in understanding and respecting patients’ preferences. Health Aff (Millwood) 2017;36:12521257.

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 2451 723 88
PDF Downloads 808 338 45
EPUB Downloads 0 0 0