‘Advance care planning works’ for patients with cancer, meta-analysis shows
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Key takeaways:
- The study follows opinion pieces questioning the value of advance care planning.
- Previous studies had relied upon narrative synthesis of the existing data.
Patients with cancer who took part in advance care planning tended to have less aggressive and more comfort-based end-of-life care than those who did not, according to a study conducted by researchers at Regenstrief Institute.
“Advance care planning was solidified as an important aspect of high-quality health care delivery with the passing of the Patient Self-Determination Act (PSDA) in 1990,” Kristin Levoy, PhD, MSN, RN, assistant professor at Indiana University School of Nursing and research scientist at Indiana University Center for Aging Research at Regenstrief Institute, told Healio. “In looking back at these past 30 or so years since the passing of the PSDA, there have been concerns about whether advance care planning has achieved what it set out to do, which was to ensure that patients have a way to document their preferences in advance so that in the event that they cannot speak for themselves, they ultimately receive care that is matched to their personal goals.”
These concerns have given rise to opinion pieces in the research literature that have called the value of advance care planning into question.
Suspecting it might be premature to draw conclusions about advance care planning, Levoy and colleagues decided to take a more statistical approach to answer this question.
“At least some of these concerns about advance care planning were formed by narrative synthesis of what has worked or not worked over the past 30 years,” Levoy said. “We don’t want to be so hasty in concluding that advance care planning hasn’t accomplished anything based on narrative reviews alone. Our thought was that we should put some statistical power behind trying to answer these questions.”
Levoy spoke with Healio about the value of a statistical analysis of the literature, the trends her study of 33,541 patients with cancer revealed, and the potential implications of these findings in the future.
Healio: What was the value of conducting a meta-analysis of the literature on advance care planning?
Levoy: The meta-analysis method allows us to pool statistical findings from individual studies and run them as a collective whole. That allows us to make some stronger conclusions about whether or not advance care planning is working or not. We also wanted to look at advance care planning in a defined context. Many of the narrative reviews looked at advance care planning in a variety of illness states. We decided to be very specific about the context in which we answer this question. We narrowed it down to the population of patients with cancer, and we also narrowed it down to studies solely looking at the role of advance care planning, not advance planning embedded as part of another set of services. So, we were very strategic about the idea that if we were going to put some math behind this, we needed to make it a very clean assessment in a very defined context.
Healio: What did you find?
Levoy: The main conclusion is that advance care planning works. When patients have engaged in advance care planning, they tend to receive care at the end of life that is in the direction of more comfort-based interventions and avoid aggressive treatments that typically prolong death, rather than prolong life. This includes avoiding things like receiving mechanical ventilation or being admitted to an ICU or hospital within the last 30 days of life. Advance care planning helps patients avoid the kind of care most would say they don’t want to receive at the end of life.
There are some patients who do want aggressive care at the end of life, and by all means, they should have that care if they want. However, if you were to ask the general public, most would say they want to die at home, with loved ones at their bedside and with their pain controlled. So, we found that with advance care planning, if patients are engaged in this preparatory process to guide future in-the-moment decision-making, we are helping them to achieve the death that they would prefer.
Healio: What do you expect to be the implications of these findings?
Levoy: Another significant finding from our study was that advance care planning had a differential impact depending on the “shape and size” of its delivery. We wanted to look at the different forms of advance care planning delivered across studies. Did we see greater impact at the end of life when advance care planning was implemented in certain ways?
What we found was that studies that treated advance care planning as a process of communication saw greater benefits than studies that treated advance care planning as a transactional, “one-and-done” process of document completion. Advance care planning in any form was helpful, but what was even more helpful and had greater benefit was when studies tended to the communication processes of advance care planning. That’s important in that it suggests we are watering down the effects of advance care planning if we’re not having those meaningful conversations. That’s a significant finding in terms of how we are moving forward. We have a lot of room for improvement when it comes to thinking about how best to engage both patients and caregivers in a targeted, meaningful communication that occurs as a part of the advance care planning process.
For more information:
Kristin Levoy, PhD, MSN, RN, can be reached at Department of Community and Health Systems, Indiana University School of Nursing, 600 Barnhill Drive #423, Indianapolis, IN 46202; email: klevoy@iu.edu. Twitter: @KristinLevoy.
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