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Original Investigation |

Trends in Advance Care Planning in Patients With Cancer Results From a National Longitudinal Survey

Amol K. Narang, MD1; Alexi A. Wright, MD, MPH2,3; Lauren H. Nicholas, PhD, MPP4,5
[+] Author Affiliations
1Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
2Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
3Harvard Medical School, Boston, Massachusetts
4Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
5Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
JAMA Oncol. 2015;1(5):601-608. doi:10.1001/jamaoncol.2015.1976.
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Importance  Advance care planning (ACP) may prevent end-of-life (EOL) care that is nonbeneficial and discordant with patient wishes. Despite long-standing recognition of the merits of ACP in oncology, it is unclear whether participation in ACP by patients with cancer has increased over time.

Objectives  To characterize trends in durable power of attorney (DPOA) assignment, living will creation, and participation in discussions of EOL care preferences and to explore associations between ACP subtypes and EOL treatment intensity as reflected in EOL care decisions and terminal hospitalizations.

Design, Setting, and Participants  We analyzed prospectively collected survey data from 1985 next-of-kin surrogates of Health and Retirement Study (HRS) participants with cancer who died between 2000 and 2012, including data from in-depth “exit” interviews conducted with the surrogates after the participant’s death. The HRS is a nationally representative, biennial, longitudinal panel study of US residents older than 50 years. Trends in ACP subtypes were tested, and multivariable logistic regression models examined for associations between ACP subtypes and measures of treatment intensity.

Main Outcomes and Measures  Trends in the surrogate-reported frequency of DPOA assignment, living will creation, and participation in discussions of EOL care preferences; associations between ACP subtypes and both surrogate-reported EOL care decisions and terminal hospitalizations.

Results  From 2000 to 2012, there was an increase in DPOA assignment (52% to 74%, P = .03), without significant change in use of living wills (49% to 40%, P = .63) or EOL discussions (68% to 60%, P = .62). Surrogate reports that patients received “all care possible” at EOL increased during the period (7% to 58%, P = .004), and rates of terminal hospitalizations were unchanged (29% to 27%, P = .70). Limiting or withholding treatment was associated with living wills (adjusted odds ratio [AOR], 2.51; 95% CI, 1.53-4.11; P < .001) and EOL discussions (AOR, 1.93; 95% CI, 1.53-3.14; P = .002) but not with DPOA assignment.

Conclusions and Relevance  Use of DPOA increased significantly between 2000 and 2012 but was not associated with EOL care decisions. Importantly, there was no growth in key ACP domains such as discussions of care preferences. Efforts that bolster communication of EOL care preferences and also incorporate surrogate decision makers are critically needed to ensure receipt of goal-concordant care.

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Figure 1.
Adjusted Yearly Percentages of Advance Care Planning (ACP) and Subtypes Over Time
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Figure 2.
Adjusted Yearly Percentages of End-of-Life (EOL) Treatment Intensity Over Time
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