Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness

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  • 1 Department of International Business, Soochow University, and
  • | 2 School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC;
  • | 3 Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC;
  • | 4 Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC;
  • | 5 Chang Gung University, School of Nursing, Tao-Yuan, Taiwan, ROC; and
  • | 6 Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung City, Taiwan, ROC.
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Background: Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders. Patients and Methods: Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling. Results: At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036–4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989–89.786; P=.008). Both arms issued DNR orders close to death (median, 5–6 days before death). Conclusions: Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.

ClinicalTrial.gov Identification: NCT01912846

Submitted February 17, 2020; accepted for publication May 29, 2020.

Author contributions: Study concept and design: All authors. Provision of study material or patients: Chou, J.S. Chen, Chang, Hsieh. Data collection and/or assembly: All authors. Data analysis and interpretation: Wen, Tang. Manuscript writing: Tang. Final approval of manuscript: All authors.

Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This article was supported by the National Health Research Institutes (NHRI-EX106-10208PI) and partially supported by the National Health Research Institutes (NHRI-EX109-10704PI), the Ministry of Science and Technology (MOST 105-2314-B-182-040-MY3), and Chang Gung Memorial Hospital (BMRP888).

Disclaimer: The data that were generated and/or analyzed during the current study are not publicly available because of restrictions by the Taiwanese government but are available from the corresponding author upon reasonable request. No funding source had any role in designing and conducting the study; collecting, managing, analyzing, and interpreting the data; or preparing, reviewing, or approving the manuscript.

Correspondence: Siew Tzuh Tang, DNSc, Chang Gung University, School of Nursing, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan 33303, Taiwan, ROC. Email: sttang@mail.cgu.edu.tw

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  • 1.

    Bruckel JT, Wong SL, Chan PS, et al. . Patterns of resuscitation care and survival after in-hospital cardiac arrest in patients with advanced cancer. J Oncol Pract 2017;13:e821830.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Reisfield GM, Wallace SK, Munsell MF, et al. . Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation 2006;71:152160.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Heyland DK, Frank C, Groll D, et al. . 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
  • 4.

    Miaris N, Samantas E, Siafaka I, et al. . Views of cancer patients regarding cardiopulmonary resuscitation in Greece. Eur J Cancer Care (Engl) 2018;27:e12850.

  • 5.

    Rubin EB, Buehler A, Halpern SD. Seriously ill patients’ willingness to trade survival time to avoid high treatment intensity at the end of life. JAMA Intern Med 2020;180:907909.

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

    Sanders JJ, Curtis JR, Tulsky JA. Achieving goal-concordant care: a conceptual model and approach to measuring serious illness communication and its impact. J Palliat Med 2018;21(S2):S1727.

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

    Sudore RL, Heyland DK, Lum HD, et al. . Outcomes that define successful advance care planning: a Delphi panel consensus. J Pain Symptom Manage 2018;55:245255.e8.

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

    El-Jawahri A, Lau-Min K, Nipp RD, et al. . Processes of code status transitions in hospitalized patients with advanced cancer. Cancer 2017;123:48954902.

  • 9.

    Levin TT, Li Y, Weiner JS, et al. . How do-not-resuscitate orders are utilized in cancer patients: timing relative to death and communication-training implications. Palliat Support Care 2008;6:341348.

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

    Caissie A, Kevork N, Hannon B, et al. . Timing of code status documentation and end-of-life outcomes in patients admitted to an oncology ward. Support Care Cancer 2014;22:375381.

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

    Wang Z, Li YS, Zhao N, et al. . Do-not-resuscitate orders among advanced-stage Chinese lung cancer patients who died in hospital. Support Care Cancer 2016;24:17631769.

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

    Huang BY, Chen HP, Wang Y, et al. . The do-not-resuscitate order for terminal cancer patients in mainland China: a retrospective study. Medicine (Baltimore) 2018;97:e0588.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Shih TC, Chang HT, Lin MH, et al. . Differences in do-not-resuscitate orders, hospice care utilization, and late referral to hospice care between cancer and non-cancer decedents in a tertiary hospital in Taiwan between 2010 and 2015: a hospital-based observational study. BMC Palliat Care 2018;17:18.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Baek SK, Chang HJ, Byun JM, et al. . The association between end-of-life care and the time interval between provision of a do-not-resuscitate consent and death in cancer patients in Korea. Cancer Res Treat 2017;49:502508.

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

    Enguidanos S, Ailshire J. Timing of advance directive completion and relationship to care preferences. J Pain Symptom Manage 2017;53:4956.

  • 16.

    Osinski A, Vreugdenhil G, de Koning J, et al. . Do-not-resuscitate orders in cancer patients: a review of literature. Support Care Cancer 2017;25:677685.

  • 17.

    Patel K, Sinvani L, Patel V, et al. . Do-not-resuscitate orders in older adults during hospitalization: a propensity score-matched analysis. J Am Geriatr Soc 2018;66:924929.

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

    Sasaki A, Hiraoka E, Homma Y, et al. . Association of code status discussion with invasive procedures among advanced-stage cancer and noncancer patients. Int J Gen Med 2017;10:207214.

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

    Torke AM, Sachs GA, Helft PR, et al. . Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker. J Am Geriatr Soc 2011;59:13261331.

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

    Mack JW, Weeks JC, Wright AA, et al. . 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
  • 21.

    Enzinger AC, Zhang B, Schrag D, et al. . Outcomes of prognostic disclosure: associations with prognostic understanding, distress, and relationship with physician among patients with advanced cancer. J Clin Oncol 2015;33:38093816.

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

    Shen MJ, Trevino KM, Prigerson HG. The interactive effect of advanced cancer patient and caregiver prognostic understanding on patients’ completion of do not resuscitate orders. Psychooncology 2018;27:17651771.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Keating NL, Landrum MB, Rogers SO Jr, et al. . Physician factors associated with discussions about end-of-life care. Cancer 2010;116:9981006.

  • 24.

    Mori M, Shimizu C, Ogawa A, et al. . A national survey to systematically identify factors associated with oncologists’ attitudes toward end-of-life discussions: what determines timing of end-of-life discussions? Oncologist 2015;20:13041311.

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

    Johnson S, Butow P, Kerridge I, et al. . 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
  • 26.

    Epstein RM, Duberstein PR, Fenton JJ, et al. . 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
  • 27.

    Leighl NB, Shepherd HL, Butow PN, et al. . Supporting treatment decision making in advanced cancer: a randomized trial of a decision aid for patients with advanced colorectal cancer considering chemotherapy. J Clin Oncol 2011;29:20772084.

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

    Temel JS, Greer JA, Admane S, et al. . Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol 2011;29:23192326.

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

    Temel JS, Greer JA, El-Jawahri A, et al. . Effects of early integrated palliative care in patients with lung and gi cancer: a randomized clinical trial. J Clin Oncol 2017;35:834841.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Yun YH, Lee MK, Park S, et al. . Use of a decision aid to help caregivers discuss terminal disease status with a family member with cancer: a randomized controlled trial. J Clin Oncol 2011;29:48114819.

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

    Kirchhoff KT, Hammes BJ, Kehl KA, et al. . 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
  • 32.

    Houben CHM, Spruit MA, Groenen MTJ, et al. . Efficacy of advance care planning: a systematic review and meta-analysis. J Am Med Dir Assoc 2014;15:477489.

  • 33.

    Bestvina CM, Polite BN. Implementation of advance care planning in oncology: a review of the literature. J Oncol Pract 2017;13:657662.

  • 34.

    Epstein AS, Volandes AE, Chen LY, et al. . A randomized controlled trial of a cardiopulmonary resuscitation video in advance care planning for progressive pancreas and hepatobiliary cancer patients. J Palliat Med 2013;16:623631.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Stein RA, Sharpe L, Bell ML, et al. . Randomized controlled trial of a 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
  • 36.

    Patel MI, Sundaram V, Desai M, et al. . Effect of a lay health worker intervention on goals-of-care documentation and on health care use, costs, and satisfaction among patients with cancer: a randomized clinical trial. JAMA Oncol 2018;4:13591366.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37.

    Tang ST, Chen JS, Wen FH, et al. . Advance care planning improves psychological symptoms but not quality of life and preferred end-of-life care of patients with cancer. J Natl Compr Canc Netw 2019;17:311320.

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

    Chen CH, Chen JS, Wen FH, et al. . An individualized, interactive intervention promotes terminally ill cancer patients’ prognostic awareness and reduces cardiopulmonary resuscitation received in the last month of life: secondary analysis of a randomized clinical trial. J Pain Symptom Manage 2019;57:705714.e7.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

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

  • 40.

    Chen CH, Kuo SC, Tang ST. Current status of accurate prognostic awareness in advanced/terminally ill cancer patients: Systematic review and meta-regression analysis. Palliat Med 2017;31:406418.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41.

    Mockford C, Fritz Z, George R, et al. . Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation. Resuscitation 2015;88:99113.

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

    Tango T. Repeated measures design. In: Tango T. Repeated Measures Design With Generalized Linear Mixed Models for Randomized Controlled Trials. London, United Kingdom: Chapman and Hall; 2017: 117.

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

    Mallinckrodt C, Lipkovich I. Analyzing Longitudinal Clinical Trial Data—A Practical Guide. New York, NY: CRC Press, Taylor & Francis Group; 2017.

    • Search Google Scholar
    • Export Citation
  • 44.

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

  • 45.

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

  • 46.

    Kim DY, Lee KE, Nam EM, et al. . Do-not-resuscitate orders for terminal patients with cancer in teaching hospitals of Korea. J Palliat Med 2007;10:11531158.

  • 47.

    Azad AA, Siow SF, Tafreshi A, et al. . Discharge patterns, survival outcomes, and changes in clinical management of hospitalized adult patients with cancer with a do-not-resuscitate order. J Palliat Med 2014;17:776781.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Field RA, Fritz Z, Baker A, et al. . Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions. Resuscitation 2014;85:14181431.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49.

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

  • 50.

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

  • 51.

    Blackhall LJ, Frank G, Murphy S, et al. . Bioethics in a different tongue: the case of truth-telling. J Urban Health 2001;78:5971.

  • 52.

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

  • 53.

    Dzeng E, Colaianni A, Roland M, et al. . Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life. JAMA Intern Med 2015;175:812819.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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