Paradoxes in Advance Care Planning: The Complex Relationship of Oncology Patients, Their Physicians, and Advance Medical Directives

Dow, Lindsay; Matsuyama, Robin K.; Ramakrishnan, Viswanathan; Kuhn, Laura; Lamont, Elizabeth B.; Lyckholm, Laurie; Smith, Thomas J.

doi:10.1200/jco.2009.24.6397

Cited by 162 publications

(169 citation statements)

References 25 publications

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“…21,22 These low LW rates are not unexpected, especially in the United States, given the paucity of advance care planning in America, 1 whether among the healthy, the elderly, the hospitalized, 23 those undergoing major surgical procedures, 24 or those with cancer. 25,26 In contrast to the low frequency of LWs, we found a much higher percentage of patients with HCPs. Our contemporary analysis replicates prior studies 1,14,15,18,27 in both oncologic and medical-surgical critically ill populations, which shows that the presence of LWs has no impact on ICU care patterns, EOL management, and outcomes.…”

Section: Discussioncontrasting

confidence: 48%

Advance Directives in an Oncologic Intensive Care Unit: A Contemporary Analysis of their Frequency, Type, and Impact

Halpern¹,

Pastores²,

Chou

et al. 2011

Journal of Palliative Medicine

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Background: Our objective was to provide a contemporary analysis of the prevalence, types, and impact of advance health care directives in critically ill cancer patients. Methods: We retrospectively reviewed all intensive care unit (ICU) admissions ( January 1, 2006 to April 25, 2008 at an oncologic center and identified all patients who completed a living will (LW), or health care proxy (HCP), or neither prior to ICU admission. Demographics, clinical data, end-of-life (EOL) parameters and outcomes were compared among three groups: LWs, HCPs, and no LW or HCP. Results: Of 1,333 ICU admissions, 1,121 patients (84%) were included for analysis: 176 patients (15.7%) had LW, 534 (47.6%) had HCP and 411 (36.7%) had no LW or HCP. Patients with LW were significantly more likely to be older and white as compared to patients with HCP alone, or no LW or HCP. There were no significant demographic differences between patients with HCP or no LW or HCP. Patients with HCP alone, or no LW or HCP, were significantly more likely to have Medicaid than patients with LW. There were no differences noted in ICU care, EOL management, or outcomes among the three groups. Conclusions: The prevalence of LWs in patients admitted to our oncologic ICU is low. More than half of the remaining patients had designated HCPs. Older age and white race were associated with the presence of LWs. However, the presence of LWs or HCPs did not influence ICU care, EOL management or outcomes at our institution.

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Section: Discussioncontrasting

confidence: 48%

Advance Directives in an Oncologic Intensive Care Unit: A Contemporary Analysis of their Frequency, Type, and Impact

Halpern¹,

Pastores²,

Chou

et al. 2011

Journal of Palliative Medicine

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“…In the report of the Virginia patients, only 7% reported having an AD discussion with their oncologist; moreover, only 23% said they would like to discuss AD with their oncologist (5). When Snyder and colleagues surveyed primary care physicians regarding their understanding of and experience with advance care planning (2), they found that only 43% reported having those discussions with the appropriate patients; 44% felt that the discussions took too much time, and most felt that the appropriate time to have the conversation was in the estimated last 6 months of life (6). Th e inclusion of other specialists and mid-level providers may help overcome the time constraints that some physicians face.…”

Section: Discussionmentioning

confidence: 99%

“…Another study of patients admitted to a hematology-oncology inpatient service in Virginia provided information about their preferences and attitudes toward AD and which physicians they preferred to host the discussion (6). Of the 75 patients enrolled in the study, nearly all (95%) thought that discussing an AD was very or somewhat important, but only 41% had an existing AD.…”

mentioning

confidence: 99%

Advance Care Planning Knowledge and Documentation in a Hospitalized Cancer Population

Barakat

Barnes²,

Casanova³

et al. 2013

Baylor University Medical Center Proceedings

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To have a better understanding of our patients' knowledge of advance directive planning and execution, as well as communication with their oncologists regarding their wishes, we conducted a survey on our inpatient hematology-oncology services. A total of 68 unique hospitalized patients with a diagnosis of cancer completed surveys. Surveys were given to all oncology patients regardless of their reason for admission. Overall, 29% of the patients reported having had a discussion with their oncologist regarding their wishes if they became seriously ill or near death. Of those who did have this conversation, the majority said that they, rather than their physician, initiated it. Although the vast majority of patients (97%) knew what a living will was, only 54% had one in place. Twenty patients had a discussion with their oncologist, and 14 of them (70%) had a living will. This percentage was higher than in the group that did not have a conversation with their physician (48%; 23 of 48 patients), but the difference was not statistically significant. Most cancer patients admitted to an inpatient oncology unit either did not have or did not recall having a discussion with their oncologist regarding endof-life issues. This study gives us a baseline of information in evaluating future interventions directed to improve the quality of patient-physician communication regarding end-of-life planning.

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“…Preceding surveys showed that 20-40% of cancer patients report on having a completed AD (living will and/or durable power of attorney for health care) and that this rate has remained constant over many years [3,4,5,6]. It seems to be even lower than 20% in different European countries independent of the detailed legal situation [7,8,9,10,11,12].…”

Section: Introductionmentioning

confidence: 99%

“…A recent investigation challenged this conclusion and showed that cancer patients would prefer their oncologist if he made ‘the first step' toward initiating an AD discussion [4]. These surveys only included hospitalized cancer patients.…”

Section: Introductionmentioning

confidence: 99%

The Impact of a Tumor Diagnosis on Patients' Attitudes toward Advance Directives

et al. 2014

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Background: Although advance care planning and the completion of advance directives (ADs) are important tools to avoid unwanted aggressive care once patients have lost their decision-making capacity, only a minority of cancer patients are admitted with completed ADs, and little is known about patients' wishes regarding AD consultations. Methods: For 1 year, every new patient admitted to the hematology/oncology outpatient clinic of the University Hospital Regensburg received a self-administered questionnaire comprising a self-evaluation of AD knowledge and questions about preferences regarding consultation partners and the time of consultation. Disease-related data were collected from medical records. Statistics were calculated with SPSS. Results: Of the 500 questionnaires handed out, 394 (75%) were evaluable and analyzed. Twenty-eight percent of the participants had completed an AD (living will or health care proxy). Ninety-two percent of the participants without ADs had never received a consultation offer from any professional involved. Only 20% perceived a clear relation between cancer and AD consultations. More than 50% of the participants without ADs were in favor of consultations ‘now' or ‘in a few weeks', while more than 40% objected to AD consultations. Conclusions: Oncology patients have a large unmet demand for AD consultations. However, a relevant percentage of these patients object to AD consultations. Structured and early AD consultation offers should be made, and early discussions about indications for aggressive treatment should take place.

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Paradoxes in Advance Care Planning: The Complex Relationship of Oncology Patients, Their Physicians, and Advance Medical Directives

Cited by 162 publications

References 25 publications

Advance Directives in an Oncologic Intensive Care Unit: A Contemporary Analysis of their Frequency, Type, and Impact

Advance Directives in an Oncologic Intensive Care Unit: A Contemporary Analysis of their Frequency, Type, and Impact

Advance Care Planning Knowledge and Documentation in a Hospitalized Cancer Population

The Impact of a Tumor Diagnosis on Patients' Attitudes toward Advance Directives

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