Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care

Kristin Levoy; Suzanne S Sullivan; Jesse Chittams; Ruth L Myers; Susan E Hickman; Salimah H Meghani

doi:10.1016/j.jpainsymman.2023.02.003

Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care

J Pain Symptom Manage. 2023 Jun;65(6):e715-e743. doi: 10.1016/j.jpainsymman.2023.02.003. Epub 2023 Feb 9.

Authors

Kristin Levoy¹, Suzanne S Sullivan², Jesse Chittams³, Ruth L Myers⁴, Susan E Hickman⁵, Salimah H Meghani⁶

Affiliations

¹ Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana. Electronic address: klevoy@iu.edu.
² School of Nursing (S.S.S.), University at Buffalo, State University of New York, Buffalo, New York.
³ BECCA (Biostatistics, Evaluation, Collaboration, Consultation & Analysis) Lab, Office of Nursing Research (J.C.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania.
⁴ Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana.
⁵ Department of Community and Health Systems (K.L., R.L.M., S.E.H.), Indiana University School of Nursing, Indianapolis, Indiana; Indiana University Center for Aging Research, Regenstrief Institute (K.L., S.E.H.), Indianapolis, Indiana; Indiana University Melvin and Bren Simon Comprehensive Cancer Center (K.L., S.E.H.), Indianapolis, Indiana.
⁶ NewCourtland Center for Transitions and Health, Department of Biobehavioral Health Sciences (S.H.M.), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics (S.H.M.), University of Pennsylvania, Philadelphia, Pennsylvania.

PMID: 36764411
PMCID: PMC10192153 (available on 2024-06-01)
DOI: 10.1016/j.jpainsymman.2023.02.003

Abstract

Context: There is ongoing discourse about the impact of advance care planning (ACP) on end-of-life (EOL) care. No meta-analysis exists to clarify ACP's impact on patients with cancer.

Objective: To investigate the association between, and moderators of, ACP and aggressive vs. comfort-focused EOL care outcomes among patients with cancer.

Methods: Five databases were searched for peer-reviewed observational/experimental ACP-specific studies that were published between 1990-2022 that focused on samples of patients with cancer. Odds ratios were pooled to estimate overall effects using inverse variance weighting.

Results: Of 8,673 articles, 21 met criteria, representing 33,541 participants and 68 effect sizes (54 aggressive, 14 comfort-focused). ACP was associated with significantly lower odds of chemotherapy, intensive care, hospital admissions, hospice use fewer than seven days, hospital death, and aggressive care composite measures. ACP was associated with 1.51 times greater odds of do-not-resuscitate orders. Other outcomes-cardiopulmonary resuscitation, emergency department admissions, mechanical ventilation, and hospice use-were not impacted. Tests of moderation revealed that the communication components of ACP produced greater reductions in the odds of hospital admissions compared to other components of ACP (e.g., documents); and, observational studies, not experimental, produced greater odds of hospice use.

Conclusion: This meta-analysis demonstrated mixed evidence of the association between ACP and EOL cancer care, where tests of moderation suggested that the communication components of ACP carry more weight in influencing outcomes. Further disease-specific efforts to clarify models and components of ACP that work and matter to patients and caregivers will advance the field.

Keywords: Advance care planning; aggressive care; cancer; comfort-focused end-of-life care; communication; meta-analysis.

Publication types

Review
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Advance Care Planning*
Death
Hospice Care*
Hospices*
Humans
Neoplasms* / therapy
Terminal Care*

Abstract

Publication types

MeSH terms

Grants and funding