Objectives: Examine the extent to which financial assistance, in the form of subsidies for life-extending treatments (LETs) or cash pay-outs, distorts the demand for end-of-life treatments. Methods: A discrete choice experiment was administered to 290 cancer patients in Singapore to elicit preferences for LETs and palliative care (PC) only. Responses were fitted to a latent class conditional logistic regression model. We also quantified patients' willingness to pay to avoid and willingness to accept a less effective LETor PC only. We then simulated the effects of various LET subsidy and cash pay-out policies on treatment choices. Results: We identified 3 classes of patients according to their preferences. The first class (26.1% of sample) has a strong preference for PC and are willing to give up life expectancy gains and even pay for receiving only PC. The second class (29.8% of sample) has a strong preference for LETs and prefers to extend life regardless of cost or quality of life. The final class (44.1% of sample) prefers LETs to PC, but actively trades off costs, length and quality of life when making end-of-life treatment choices. Policy simulations show that LETsubsidies increase demand for LETs at the expense of demand for PC, but an equivalent cash payout was not shown to distort demand. Conclusions: Cancer patients have heterogeneous end-of-life preferences. LET subsidies and cash payouts have differing effects on the utilization of LETs. Policymakers should be mindful of these differences when designing healthcare financing schemes for patients with life-limiting illnesses.

Background: Although patient-centred care has become increasingly important across all medical specialties, when it comes to end of life care, research has shown that treatments ordered are not often concordant with people's expressed preferences. Patient and family engagement in Advance Care Planning (ACP) in the primary care setting could improve the concordance between patients' wishes and the healthcare received when patients cannot speak for themselves. The aim of this study was to better understand the barriers faced by older patients regarding talking to their family members and family physicians about ACP. Methods: In this multi-site cross-sectional study, three free text questions regarding reasons patients found it difficult to discuss ACP with their families or their family physicians were part of a self-administered questionnaire about patients' knowledge of and engagement in ACP. The questionnaire, which included closed ended questions followed by three probing open ended questions, was distributed in 20 family practices across 3 provinces in Canada. The free text responses were analyzed using thematic analysis and form the basis of this paper. Results: One hundred two participants provided an analyzable response to the survey when asked why they haven't talked to someone about ACP. Two hundred fifty-four answered the question about talking to their physician and 340 answered the question about talking to family members. Eight distinct themes emerged from the free text response analysis: 1. They were too young for ACP; 2. The topic is too emotional; 3. The Medical Doctor (MD) should be responsible for bringing up ACP 4. A fear of negatively impacting the patient-physician relationship; 5. Not enough time in appointments; 6. Concern about family dynamics; 7. It's not a priority; and 8. A lack of knowledge about ACP. Conclusions: Patients in our sample described many barriers to ACP discussions, including concerns about the effect these discussions may have on relationships with both family members and family physicians, and issues relating to patients' knowledge and interpretation of the importance, responsibility for, or relevance of ACP itself. Family physicians may be uniquely placed to leverage the longitudinal, person-centred relationship they have with patients to mitigate some of these barriers.

Background People who engage in advance care planning (ACP) are more likely to receive health care that is concordant with their goals at the end of life. Little discussion of ACP occurs in primary care. Objective The objective of this study was to describe primary care clinicians’ perspectives on having ACP conversations with their patients. Methods We conducted a survey of family physicians and non-physician clinicians in primary care in 2014–2015. We compared family physicians and non-physician clinicians on willingness, confidence, participation and acceptability for other clinicians to engage in six aspects of ACP (initiating, exchanging information, decision coaching, finalizing plans, helping communicate plans with family members and other health professionals) on scales from 0 = not at all/extremely unacceptable to 6 = very/all the time/extremely acceptable. Results The response rate was 72% (n = 117) among family physicians and 69% (n = 64) among non-physician clinicians. Mean ratings (standard deviation [SD]) of willingness were high (4.5 [1.4] to 5.0 [1.2] for physicians; 3.4 [1.8] to 4.6 [1.6] non-physician clinicians). There was little participation (mean ratings 2.4 [1.7] to 2.7 [1.6] for physicians, 1.0 [1.5] to 1.4 [1.7] for non-physician clinicians). Non-physician clinicians rated confidence statistically significantly lower than physicians for all ACP aspects. Acceptability for non-physician clinician involvement was high in both groups (mean acceptability ratings greater than 4). Conclusion Current engagement of primary care clinicians in ACP is low. Given the high willingness and acceptability for non-physician clinician involvement, increasing the capacity of non-physician clinicians could enable uptake of ACP in primary care.

Breakthrough cancer pain in Canadian cancer patients greatly impacts their daily lives. There is room for improvement in the management of BTPc, and the majority of patients would be willing to try new treatments.