A Prospective Cohort Study of Stability in Preferred Place of Death Among Patients With Stage IV Cancer in Singapore

Authors: Chetna Malhotra MBBS, MD, MPH1,2, Ling En Koh BSc1,2, Irene Teo PhD1,2,3, Semra Ozdemir PhD1,2, Isha Chaudhry MSc1,2, and Eric Finkelstein PhD, MHA1,2
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  • 1 Lien Centre for Palliative Care, and
  • | 2 Program in Health Services and Systems Research, Duke-NUS Medical School; and
  • | 3 Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore.

Background: Advance care planning (ACP) involves documentation of patients’ preferred place of death (PoD). This assumes that patients’ preferred PoD will not change over time; yet, evidence for this is inconclusive. We aimed to assess the extent and correlates of change in patients’ preferred PoD over time. Materials and Methods: Using data from a cohort study of patients with advanced cancer in Singapore, we analyzed preferred PoD (home vs institution including hospital, hospice, and nursing home vs unclear) among 466 patients every 6 months for a period of 2 years. At each time point, we assessed the proportion of patients who changed their preferred PoD from the previous time point. Using a multinomial logistic regression model, we assessed patient factors (demographics, understanding of disease stage, ACP, recent hospitalization, quality of life, symptom burden, psychologic distress, financial difficulty, prognosis) associated with change in their preferred PoD. Results: More than 25% of patients changed their preferred PoD every 6 months, with no clear trend in change toward home or institution. Patients psychologically distressed at the time of the survey had increased likelihood of changing their preferred PoD to home (relative risk ratio [RRR], 1.02; 95% CI, 1.00–1.05) and to an institution (RRR, 1.06; 95% CI, 1.02–1.10) relative to no change in preference. Patients hospitalized in the past 6 months were more likely to change their preferred PoD to home (RRR, 1.56; 95% CI, 1.07–2.29) and less likely to change to an institution (RRR, 0.50; 95% CI, 0.28–0.88) relative to no change in preference. Conclusions: The present study provides evidence of instability in the preferred PoD of patients with advanced cancer. ACP documents need to be updated regularly to ensure they accurately reflect patients’ current preference.

Submitted June 30, 2020; final revision received December 14, 2020; accepted for publication December 14, 2020. Published online August 5, 2021.

COMPASS Study Team members (supplemental eAppendix 1); available with this article at JNCCN.org.

Author contributions: Study concept: Malhotra, Koh. Data curation: Koh. Formal analysis: Koh, Chaudhry. Funding acquisition: Finkelstein. Investigation: COMPASS study team. Methodology: Malhotra. Project administration: COMPASS study team. Supervision: Malhotra. Writing – original draft: Koh. Writing – review and editing: Malhotra, Teo, Ozdemir, Chaudhry, Finkelstein.

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 work was supported by the Singapore Millennium Foundation and the Lien Centre for Palliative Care (LCPC-IN14-0003).

Correspondence: Chetna Malhotra, MBBS, MD, MPH, Lien Centre for Palliative Care, Duke-NUS Medical School, 8 College Road, Singapore 169857. Email: chetna.malhotra@duke-nus.edu.sg

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