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Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers

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Abstract

Purpose

The purposes of the study were to assess awareness and prevalence of advance directives (ADs) among patients with advanced cancer undergoing active outpatient care and to determine factors associated with AD completion before and after the diagnosis of cancer.

Methods

Patients with advanced solid tumor malignancy receiving treatment at the Chemotherapy Day Unit were approached for recruitment. They completed an onsite questionnaire about completion and timing of ADs, demographic information, and perceived health; a review of their medical records was conducted to document their cancer care and co-morbidities. Multinomial logistic regression analysis identified factors associated with the timing of AD completion (pre-cancer, post-cancer, or not at all).

Results

Two hundred patients were enrolled, with 193 surveys available for analysis. ADs were completed in 55 % (106/193) of patients, including a living will in 33 % (63/193), a power of attorney in 49 % (95/193), and a do-not-resuscitate (DNR) designation in 18 % (35/193). Most patients (53 %) had completed an AD before being diagnosed with cancer. Higher income (p = 0.02) and age (p = 0.004) were associated with AD completion pre-cancer diagnosis; discussion of end-of-life care (p = 0.02) and palliative care referral (p < 0.0001) were associated with AD completion post-cancer diagnosis.

Conclusions

This study demonstrates that different factors may influence the completion of ADs before and after a diagnosis of cancer and highlights the potential for early palliative care to impact the completion of ADs in patients with advanced cancer who are undergoing active cancer treatment.

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Acknowledgments

We thank the patients who participated in this study, as well as the clinical and administrative staff at the Chemotherapy Day Unit for assistance with patient eligibility. We thank Dr. Ian Tannock for his contributions to the conception and design of this study, as well as Nadia Swami and Jennifer Kotler (Department of Supportive Care, Princess Margaret Cancer Centre) for their assistance with preparation of study materials, recruitment of patients, and data entry and preparation. This research was funded by the Ontario Ministry of Health and Long-Term Care. CZ is supported by the Rose Chair in Supportive Care, Faculty of Medicine, University of Toronto. The views expressed in the study do not necessarily represent those of the sponsors. The funding agencies had no role in the design or conduct of the study; the collection, analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript.

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Authors and Affiliations

  1. Department of Medicine, Division of Medical Oncology, University of Toronto, Toronto, ON, Canada

    Julie C. McDonald & Camilla Zimmermann

  2. Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, 16th floor, Toronto, ON, M5G 2M9, Canada

    Julie C. McDonald, Nanor Kevork & Camilla Zimmermann

  3. Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada

    Lisa W. Le

  4. Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada

    Camilla Zimmermann

  5. Department of Medicine, Mississauga Hospital, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada

    Jeanne M. du Manoir

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  1. Julie C. McDonald
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Correspondence to Camilla Zimmermann.

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McDonald, J.C., du Manoir, J.M., Kevork, N. et al. Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers. Support Care Cancer 25, 523–531 (2017). https://doi.org/10.1007/s00520-016-3433-6

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  • DOI: https://doi.org/10.1007/s00520-016-3433-6

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