Patient–caregiver dyads advance care plan value discussions: randomised controlled cancer trial of video decision support tool

Abstract

ObjectiveUptake of advance care planning (ACP) in cancer remains low. An emphasis on personal value discussions and adoption of novel interventions may serve as the catalyst to increase engagement. This study examined the effectiveness of a video decision support tool (VDST) modelling values conversations in cancer ACP.MethodsThis single site, open-label, randomised controlled trial allocated patient–caregiver dyads on a 1:1 ratio to VDST or usual care (UC). Previously used written vignettes were converted to video vignettes using standard methodology. We evaluated ACP document completion rates, understanding and perspectives on ACP, congruence in communication and preparation for decision-making.ResultsParticipants numbered 113 (60.4% response rate). The VDST did not improve overall ACP document completion (37.7% VDST; 36.7% UC). However, the VDST improved ACP document completion in older patients (≥70) compared with younger counterparts (<70) (OR=0.308, 95% CI 0.096 to 0.982, p=0.047), elicited greater distress in patients (p=0.015) and improved patients and caregivers ratings for opportunities to discuss ACP with health professionals. ACP improved concordance in communication (VDST p=0.006; UC p=0.045), more so with the VDST (effect size: VDST 0.7; UC 0.54). Concordance in communication also improved in both arms with age.ConclusionThe VDST failed to improve ACP document completion rates but highlighted that exploring core patient values may improve concordance in patient–caregiver communication. Striving towards a more rigorous design of the VDST intervention, incorporating clinical outcome scenarios with values conversations may be the catalyst needed to progress ACP towards a more fulfilling process for those who partake in it.Trial registration numberACTRN12620001035910.

Interventions aiming to improve advance care planning uptake in oncology: a scoping review of recent randomized controlled trials

“…Interventions in this category involved the use of a question prompt list (QPL; one RCT) [12] and videos (two RCTs) [13][14][15][16]. The QPL was adapted from a booklet used in America and Australia [43], to promote discussions about prognoses and EoL issues with patients with advanced cancer and estimated life expectancies less than 1 year attending outpatient palliative care consultations [12].…”

“…In another RCT, the effectiveness of a video decision support tool (VDST) based on video vignettes designed to facilitate value-based ACP discussions across three cancer trajectory stages among patients with cancer and their designated caregivers was examined [ 14 ]. Relative to usual care (receipt of the hospital's ACP document and verbal and written guidelines) [ 14 ], the intervention had no impact on ACP document completion overall, but it enhanced such completion in older (aged ≥70 years) relative to younger (aged <70 years) patients [ 15 ]. Qualitative analyses of the contents of patients’ ACP value directives revealed that the choices people make as they approach death relate to their most deeply held values, highlighting the usefulness of discussing value directives during ACP [ 16 ].…”

“…The cancer care contexts, intervention modalities, and main outcomes were heterogeneous. The interventions were primarily multimodal and of three main types: those that aimed to improve ACP uptake via patient/caregiver-oriented tools (three RCTs) [12–16], those involving trained ACP facilitators’ support of patients and caregivers [six RCTs, including one targeting adolescent and young-adult (AYA) patients] [17,18 ▪ ,19–37], and one involving the prompting of trained physicians’ implementation of ACP discussions in practice (one RCT) [38,39 ▪ ,40–42]. Patient, caregiver, HCP, and healthcare service outcomes were measured.…”