An Intervention to Increase Advance Care Planning Among Older Adults With Advanced Cancer: A Randomized Clinical Trial
Open accessAbstract
Importance: Many older adults with advanced cancer never communicate goals of care or treatment preferences to their clinicians, raising the risk that care received will not match their values. Scalable models of care may help surmount this barrier. Objective: To test whether a combined patient and clinician intervention increased the rate of advance care planning (ACP) documentation in large health care systems. Design, Setting, and Participants: This stepped-wedge cluster randomized clinical trial using an open cohort design included patients aged 65 years or older with advanced cancer seen at oncology clinics in 3 health care systems located in the US South, Midwest, and Mid-Atlantic regions from April 1, 2020, to November 30, 2022. Data collection ended in 2024. Intervention: The intervention involved delivering brief evidence-based patient-facing video decision aids available in 25 languages as well as goals-of-care communication training to oncology clinicians. Patients in the control period received usual care. Main Outcomes and Measures: The primary outcome was ACP documentation, which included any electronic health record documentation of a goals-of-care conversation, palliative care, hospice, or limitation of life-sustaining treatments, identified via a validated natural language processing program. Analysis was performed on an intention-to-treat basis. Results: Twenty-nine practices, comprising 13 800 unique eligible patients with a total of 29 357 repeated measurements, were included (mean [SD] age, 74.5 [6.6] years; 52.3% men [15 344 of 29 357 measurements]). The proportion of patients with ACP documentation was greater in the intervention phase compared with the usual care phase (adjusted rate difference, 6.8% [95% CI, 2.8%-10.8%]; P < .001). ACP documentation in the intervention phase occurred among 3980 of 15 754 patients (25.3%) (goals-of-care conversation, 21.4% [3377 of 15 754]; palliative care, 9.6% [1517 of 15 754]; hospice, 5.4% [847 of 15 754]; and limitation of life-sustaining treatments, 7.2% [1128 of 15 754]). In comparison, ACP documentation in the usual care phase occurred among 2834 of 13 603 patients (20.8%) (goals-of-care conversation, 16.8% [2281 of 13 603]; palliative care, 9.5% [1287 of 13 603]; hospice, 5.3% [724 of 13 603]; and limitation of life-sustaining treatments, 8.4% [1149 of 13 603]). Conclusions and Relevance: In this stepped-wedge cluster randomized clinical trial for older adults with advanced cancer, a bundled evidence-based decision aid and communication training intervention increased the proportion of older patients with ACP documentation. This approach offers an innovative paradigm with a clinically meaningful increase in ACP documentation, a widely used quality metric that reflects high-quality patient-centered care delivery. Trial Registration: ClinicalTrials.gov Identifier: NCT03609177
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To date, use of NLP to identify goals-of-care discussions has facilitated at least two clinical trials.
“To date, the use of NLP to identify this linguistically complex outcome has facilitated at least two clinical trials;19–22 and, while current clinical EHRs rely on either search-based approaches or the use of semi-structured documentation,12,23 real-time ability for clinicians to efficiently locate goals-of-care documentation seems likely to improve delivery of goal-concordant care.24”
From Assessment of a Zero-Shot Large Language Model in Measuring Documented Goals-of-Care Discussions (2026) · cites this paper as [22]
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- Authors
- Volandes, A. E., Chang, Y., Lakin, J. R., Paasche-Orlow, M. K., Lindvall, C., Zupanc, S. N., Martins-Welch, D., Carney, M. T., Burns, E. A., Itty, J., Emmert-Tangredi, K., Martin, N. J., Sanghani, S., Tilburt, J., Pollak, K. I., Davis, A. D., Garde, C., Barry, M. J., El-Jawahri, A., Quintiliani, L., Sciacca, K., Goldman, J., & Tulsky, J. A.
- Affiliations
- Dartmouth College (US)
- Massachusetts General Hospital (US)
- Brigham and Women's Hospital (US)
- Department of Medicine, Tufts University School of Medicine, Tufts Medical Center, Boston, Massachusetts
- Department of Supportive Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Northwell Health (US)
- Feinstein Institute for Medical Research (US)
- Institute of Health System Science, Feinstein Institutes for Medical Research, Manhasset, New York
- Mayo Clinic (US)
- Duke University (US)
- ACP Decisions, Waban, Massachusetts
- Harvard University (US)
- Tufts University (US)
- Dana-Farber Cancer Institute (US)
- Corresponding author
- Volandes, Angelo E.
- ORCID
- Venue
- JAMA Network Open
- Publisher
- American Medical Association (AMA)
- Published
- 2025-05-09
- Volume
- 8
- Issue
- 5
- Pages
- e259150
- ISSN
- 2574-3805 (ISSN-L)
- PMC
- PMC12065034
- OpenAlex
- W4410232189
- Cited by
- 24
- References
- 41
- Citations by year
- 2026: 15 · 2025: 9
- FWCI
- 21.85
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- JAMA Network Open (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- Healthwise
- Incyte
- National Institutes of Health
- National Institute on Aging (UG3AG060626, UH3AG060626)
- National Heart, Lung, and Blood Institute
- National Cancer Institute (P30CA023108)
- National Institute of Nursing Research
- National Institute of Allergy and Infectious Diseases
- National Institute of Arthritis and Musculoskeletal and Skin Diseases
- Office of Behavioral and Social Sciences Research (UG3/UH3)
- Office of Disease Prevention
- National Institute on Minority Health and Health Disparities
- National Center for Complementary and Integrative Health (U24AT009676)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Keywords
- advance care planning, older adults, advanced cancer, clinician training, palliative care, hospice, shared decision-making, patient-clinician communication, health care system, oncology clinic, end-of-life care
- MeSH terms
- Aged, Aged, 80 and over, Documentation, Female, Humans, Male, Neoplasms, Palliative Care, Advance Care Planning
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