The Association between Chronic Conditions, End-of-Life Health Care Use, and Documentation of Advance Care Planning among Patients with Cancer

Abstract

Background: Multiple chronic conditions (MCCs) are associated with increased intensity of end-of-life (EOL) care, but their effect is not well explored in patients with cancer. Objective: We examined EOL health care intensity and advance care planning (ACP) documentation to better understand the association between MCCs and these outcomes. Design: Retrospective cohort study. Setting/Subjects: Patients aged 18+ years at UW Medicine who died during 2010-2017 with poor prognosis cancer, with or without chronic liver disease, chronic pulmonary disease, coronary artery disease, dementia, diabetes with end-stage organ damage, end-stage renal disease, heart failure, or peripheral vascular disease. Measurements: ACP documentation 30+ days before death, in-hospital death, and inpatient or intensive care unit (ICU) admission in the last 30 days. We performed logistic regression for outcomes. Results: Of 15,092 patients with cancer, 10,596 (70%) had 1+ MCCs (range 1-8). Patients with cancer and heart failure had highest odds of hospitalization (odds ratio [OR] 1.67, 95% confidence interval [CI] 1.46-1.91), ICU admission (OR 2.06, 95% CI 1.76-2.41), or in-hospital death (OR 1.62, 95% CI 1.43-1.84) versus patients with cancer and other conditions. Patients with ACP 30+ days before death had lower odds of in-hospital death (OR 0.65, 95% CI 0.60-0.71), hospitalization (OR 0.67, 95% CI 0.61-0.74), or ICU admission (OR 0.71, 95% CI 0.64-0.80). Conclusions: Patients with ACP 30+ days before death had lower odds of high-intensity EOL care. Further research needs to explore how to best use ACP to ensure patients receive care aligned with patient and family goals for care.

Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP)

“…This is further illustrated by a recent audit of patients with advanced cancer who also had multiple comorbidities, like congestive heart failure, chronic pulmonary disease, dementia, etc. [10]. Compared to patients with no or few chronic conditions, patients with multiple chronic conditions experience increased intensity of care at the end of life.…”

“…Over the past decade, have we made progress in "preparing patients for end of life decision-making?" Recent studies suggest there are still considerable problems with the current approach [6][7][8][9][10][11][12][13][14]16]. Health care expenditures in the last years of life are increasing at a phenomenal rate suggesting the current approach to "end of life" planning is not working [20].…”

“…It has been more than a decade since leaders in the field proposed this concept of preparing patients for future decision-making, but it was still ensconced in the context of end of life medical care [ 19 ]. Over the past decade, have we made progress in “preparing patients for end of life decision-making?” Recent studies suggest there are still considerable problems with the current approach [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 16 ]. Health care expenditures in the last years of life are increasing at a phenomenal rate suggesting the current approach to “end of life” planning is not working [ 20 ].…”

The Association of Advance Care Planning Documentation and End-of-Life Healthcare Use Among Patients With Multimorbidity

“…25,26 We refer to each of these 4 conditions as a primary condition. We have previously evaluated ACP and high-intensity end-of-life healthcare use for patients with cancer with or without multimorbidity in this database 27 and therefore did not include cancer as a primary condition group in this analysis. We included patients under the age of 65 because, although the average age of comorbidity onset is dropping in the United States, few data are available in the literature describing multimorbidity in adults under age 65.…”

The PREPARE for Your Care program increases advance care planning engagement among diverse older adults with cancer

“…Advance care planning (ACP) is a dynamic and iterative process by which adults share their values, goals, and preferences for future medical care, and it may include naming a medical decision‐maker, discussing goals of care with loved ones and clinicians, and completing advance directives (ADs) 1 . Among older adults with cancer, ACP is associated with higher patient and family satisfaction with end‐of‐life care, a higher likelihood of patients receiving care consistent with their goals, and a lower likelihood of high‐intensity end‐of‐life care 2‐5 . Furthermore, studies show that most older adults with cancer want to engage in ACP to have control over their care and alleviate family burden, among other reasons 6,7 .…”