Facilitated Versus Patient-Directed Advance Care Planning Among Patients With Advanced Cancer: A Randomized Clinical Trial.

Abstract

Purpose: Guidelines recommend advance care planning (ACP) to improve patient-centered care near the end of life (EOL), but the optimal approach is unknown. This single-blind, patient-level, randomized comparative effectiveness trial compared two patient-facing ACP interventions that are widely used but differ in costs and complexity.

Methods: Adult patients with advanced solid tumors and their caregivers were recruited from academic and community oncology clinics. Participants were randomly assigned to facilitated ACP using trained nurse facilitators versus patient-directed ACP using written and web-based tools. The primary outcome was patient-reported ACP engagement (assessed at baseline and 12 weeks using a 15-item validated survey; range, 0-5; higher scores indicate higher engagement). Secondary outcomes included advance directive completion and communication about EOL wishes.

Results: A total of 400 patients enrolled (mean [SD] age, 67.9 [10.5] years; 192 women [48%]). At 12 weeks, patients in the facilitated versus patient-directed group reported higher ACP engagement (4.34 [0.78] v 4.08 [0.82]; adjusted mean difference, 0.25 [95% CI, 0.1 to 0.4]; P = .0014) and higher odds of completing an advance directive (74.8% v 60.6%; OR, 2.52 [95% CI, 1.27 to 5.0]; P = .008). There were no significant differences between the facilitated and patient-directed groups in the odds of having a conversation about EOL wishes with family or friends (88.9% v 88%; OR, 1.13 [95% CI, 0.5 to 2.6]; P = .76) or physicians (49.6% v 40.6%; OR, 1.53 [95% CI, 0.9 to 2.7]; P = .13), and all ACP behaviors increased significantly from baseline in both groups.

Conclusion: Facilitated ACP resulted in greater increases in ACP engagement and advance directive completion than patient-directed written and web-based materials. Although some patients with advanced cancer may engage in self-directed ACP, some may need additional facilitator support.