Don't Throw the Baby Out With the Bathwater: Meta-Analysis of Advance Care Planning and End-of-life Cancer Care
Open accessAbstract
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.
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Advance care planning has been associated with earlier and increased use of hospice care, reduced intensive treatment and hospitalizations at the end of life, and better quality of life in patients with cancer and caregivers.
“Advance care planning has been associated with earlier and increased use of hospice care [12–15], reduced intensive treatment and hospitalizations at the end of life [13, 15–18], and better quality of life in patients with cancer and caregivers [12, 19].”
From Mindfulness to enhance quality of life and support advance care planning: a pilot randomized controlled trial for adults with advanced cancer and their family caregivers. (2024) · cites this paper as [17]
The Results section reports that advance care planning was associated with lower odds of chemotherapy, ICU admission, hospital admission, and hospice stays shorter than seven days in patients with cancer. It does not establish increased hospice use overall: the Comfort-focused EOL Care Outcomes section reports a nonsignificant overall association, although observational studies showed an association. The paper does not report improved quality of life for patients with cancer and caregivers as a finding of this meta-analysis. No page numbers were supplied in our copy. (LLM, conf=0.88)
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Wittenberg-Lyles, E. M., Sullivan, S. S., & Rios, M. (2023) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/10499091231200639 · Cited by 4 · see citing works
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- Authors
- Levoy, K., Sullivan, S. S., Chittams, J., Myers, R. L., Hickman, S. E., & Meghani, S. H.
- Affiliations
- Indiana University Health (US)
- University at Buffalo, State University of New York (US)
- University of Pennsylvania (US)
- Indiana University Indianapolis (US)
- Leonard Davis Institute of Health Economics (US)
- Corresponding author
- Levoy, Kristin
- Venue
- Journal of Pain and Symptom Management
- Publisher
- Elsevier BV
- Published
- 2023-06
- Volume
- 65
- Issue
- 6
- Pages
- e715-e743
- ISSN
- 0885-3924 (ISSN-L)
- PMC
- PMC10192153
- OpenAlex
- W4319786297
- Cited by
- 35
- References
- 71
- Citations by year
- 2026: 5 · 2025: 12 · 2024: 9 · 2023: 9
- FWCI
- 1.73
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Pain and Symptom Management (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- IUScholarWorks (Indiana University) (submittedVersion)
- Funders
- National Institute of Nursing Research (F31 NR016394, T32 NR009356)
- National Library of Medicine (T15 LM012495)
- National Institutes of Health
- Robert Wood Johnson Foundation
- American Cancer Society (131753-DSCN-18-072-SCN)
- National Institute on Aging (R01 AG056618, R01 AG057733, R01 NR017853, R03 AG067159, R33 AG057353)
- National Cancer Institute (R01 CA270483)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Keywords
- advance care planning, end-of-life care, cancer patients, aggressive care, comfort care, hospitalization, hospice use, do-not-resuscitate orders, chemotherapy, intensive care, in-hospital mortality
- MeSH terms
- Death, Hospices, Humans, Neoplasms, Terminal Care, Hospice Care, Advance Care Planning
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