Room for improvement: An examination of advance care planning documentation among gynecologic oncology patients

Abstract

Objectives The goals of this study were: (1) to evaluate patients’ knowledge regarding advance directives and completion rates of advance directives among gynecologic oncology patients and (2) to examine the association between death anxiety, disease symptom burden, and patient initiation of advance directives. Methods 110 gynecologic cancer patients were surveyed regarding their knowledge and completion of advance directives. Patients also completed the MD Anderson Symptom Inventory (MDASI) scale and Templer’s Death Anxiety Scale (DAS). Descriptive statistics were utilized to examine characteristics of the sample. Fisher’s exact tests and 2-sample t-tests were utilized to examine associations between key variables. Results Most patients were white (76.4%) and had ovarian (46.4%) or uterine cancer (34.6%). Nearly half (47.0%) had recurrent disease. The majority of patients had heard about advance directives (75%). Only 49% had completed a living will or medical power of attorney. Older patients and those with a higher level of education were more likely to have completed an advance directive (p<0.01). Higher MDASI Interference Score (higher symptom burden) was associated with patients being less likely to have a living will or medical power of attorney (p=0.003). Higher DAS score (increased death anxiety) was associated with patients being less likely to have completed a living will or medical power of attorney (p=0.03). Conclusion Most patients were familiar with advance directives, but less than half had created these documents. Young age, lower level of education, disease-related interference with daily activities, and a higher level of death anxiety were associated with decreased rates of advance directive completion, indicating these may be barriers to advance care planning documentation. Young patients, less educated patients, patients with increased disease symptom burden, and patients with increased death anxiety should be targeted for advance care planning discussions as they may be less likely to engage in advance care planning.

Factors influencing the engagement of cancer patients with advance care planning: A scoping review

“…Covidence identified 311 duplicates, resulting in 629 papers that were screened on title and abstract by all authors. A total of 73 were retrieved for full‐text screening, of which eleven met all inclusion criteria (Balboni et al, ; Bires, Franklin, Nichols, & Cagle, ; Brown et al, ; Carrion, Nedjat‐Haiem, Martinez‐Tyson, & Castañeda, ; Garrido, Harrington, & Prigerson, ; Hanratty et al, ; Kurita et al, ; Loggers & Prigerson, ; Pfirstinger, Kattner, Edinger, Andreesen, & Vogelhuber, ; Sherman et al, ; Tang et al, ). Authors ES, OG, SM and SD were involved in the full‐text screening.…”

Advance directives in cancer patients

“…20 In the MD Anderson Cancer Center in Houston, of the 110 women diagnosed with gynecological cancer, 49% (54 patients) had AD, but only 37% of them had copies of these documents in hand if necessary. 14 In this same study, 73% of patients who had cancer recurrence had more access to information on AD, but this condition did not increase the proportion of AD filling, remaining at 48%.…”

“…Regarding the expression of wishes of care at end-of-life, 66% of patients had talked with the family; 9%, with lawyer; 6%, with the palliative care team; 3% with the oncologist; 2% with the family physician and 31% had not discussed their endof-life care wishes with anyone. 16 Age, 21 level of education and high income, worse Performace Status (PS), 14,16,18 prolonged treatment and follow up with a team of palliative care, were positive factors related to the development of Advance Directives by cancer patients. The oncologist had the lowest representation among health professionals and family in the formulation process of Advance Directives.…”

“…15 In Portugal, the public discussion on AD culminated in 2012 with the approval of the Law 25/2012 that also created the National Registry of the Living Will, called RENTEV, allowing real-time access to the patients' AD within the healthcare systemintranet. 26 Articles of this study demonstrated that advanced age, 21 education level and high income 14,16,18 worsen Performance Status (PS) and also originated aprolongation 18,19 of the duration of treatment and follow up by a team of palliative care were factors that were positively related to the filling of AD in cancer patients. Some of these findings are also found in the literature, in non-oncological and oncological patients.…”

“…Some of these findings are also found in the literature, in non-oncological and oncological patients. 14,27,28 On the other hand, the lack of accessibility, information and understanding related to social conditions constituted obstacles to the performance of AD by the patients 14,19 as in the study by Jonnalagadda, 22 demonstrating the belief of American racial minorities about AD as tool that does not guarantee adequate treatment against cancer. Religion was a valued aspect and also highlighted in the study toward healing beliefs and miracles attributed to God as barriers to establishing their wills or restriction.…”