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Korfage IJ, Carreras G, Arnfeldt Christensen CM, Billekens P, Bramley L, Briggs L, Bulli F, Caswell G, Červ B, van Delden JJM, Deliens L, Dunleavy L, Eecloo K, Gorini G, Groenvold M, Hammes B, Ingravallo F, Jabbarian LJ, Kars MC, Kodba-Čeh H, Lunder U, Miccinesi G, Mimić A, Ozbič P, Payne SA, Polinder S, Pollock K, Preston NJ, Seymour J, Simonič A, Thit Johnsen A, Toccafondi A, Verkissen MN, Wilcock A, Zwakman M, van der Heide A, Rietjens JAC. Advance care planning in patients with advanced cancer: A 6-country, cluster-randomised clinical trial. PLoS Med 2020; 17:e1003422. [PMID: 33186365 PMCID: PMC7665676 DOI: 10.1371/journal.pmed.1003422] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 10/19/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Advance care planning (ACP) supports individuals to define, discuss, and record goals and preferences for future medical treatment and care. Despite being internationally recommended, randomised clinical trials of ACP in patients with advanced cancer are scarce. METHODS AND FINDINGS To test the implementation of ACP in patients with advanced cancer, we conducted a cluster-randomised trial in 23 hospitals across Belgium, Denmark, Italy, Netherlands, Slovenia, and United Kingdom in 2015-2018. Patients with advanced lung (stage III/IV) or colorectal (stage IV) cancer, WHO performance status 0-3, and at least 3 months life expectancy were eligible. The ACTION Respecting Choices ACP intervention as offered to patients in the intervention arm included scripted ACP conversations between patients, family members, and certified facilitators; standardised leaflets; and standardised advance directives. Control patients received care as usual. Main outcome measures were quality of life (operationalised as European Organisation for Research and Treatment of Cancer [EORTC] emotional functioning) and symptoms. Secondary outcomes were coping, patient satisfaction, shared decision-making, patient involvement in decision-making, inclusion of advance directives (ADs) in hospital files, and use of hospital care. In all, 1,117 patients were included (442 intervention; 675 control), and 809 (72%) completed the 12-week questionnaire. Patients' age ranged from 18 to 91 years, with a mean of 66; 39% were female. The mean number of ACP conversations per patient was 1.3. Fidelity was 86%. Sixteen percent of patients found ACP conversations distressing. Mean change in patients' quality of life did not differ between intervention and control groups (T-score -1.8 versus -0.8, p = 0.59), nor did changes in symptoms, coping, patient satisfaction, and shared decision-making. Specialist palliative care (37% versus 27%, p = 0.002) and AD inclusion in hospital files (10% versus 3%, p < 0.001) were more likely in the intervention group. A key limitation of the study is that recruitment rates were lower in intervention than in control hospitals. CONCLUSIONS Our results show that quality of life effects were not different between patients who had ACP conversations and those who received usual care. The increased use of specialist palliative care and AD inclusion in hospital files of intervention patients is meaningful and requires further study. Our findings suggest that alternative approaches to support patient-centred end-of-life care in this population are needed. TRIAL REGISTRATION ISRCTN registry ISRCTN63110516.
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Affiliation(s)
- Ida J. Korfage
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands
- * E-mail:
| | - Giulia Carreras
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Caroline M. Arnfeldt Christensen
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Palliative Medicine, Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Louise Bramley
- Institute of Nursing and Midwifery Care Excellence, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Linda Briggs
- Respecting Choices, C-TAC Innovations, Oregon, Wisconsin, United States of America
| | - Francesco Bulli
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Glenys Caswell
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Branka Červ
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Kim Eecloo
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Giuseppe Gorini
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Mogens Groenvold
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Palliative Medicine, Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Bud Hammes
- Respecting Choices, C-TAC Innovations, Oregon, Wisconsin, United States of America
| | - Francesca Ingravallo
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | | | - Marijke C. Kars
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, Netherlands
| | - Hana Kodba-Čeh
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Urska Lunder
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Guido Miccinesi
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Alenka Mimić
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Polona Ozbič
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Sheila A. Payne
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | | | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Nancy J. Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, United Kingdom
| | - Jane Seymour
- Health Sciences School, University of Sheffield, Sheffield, United Kingdom
| | - Anja Simonič
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Anna Thit Johnsen
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Palliative Medicine, Research Unit, Bispebjerg Hospital, Copenhagen, Denmark
| | - Alessandro Toccafondi
- Clinical Epidemiology, Oncological Network, Prevention and Research Institute (ISPRO), Florence, Italy
| | - Mariëtte N. Verkissen
- End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium
| | - Andrew Wilcock
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Marieke Zwakman
- Julius Centre for Health Sciences and Primary Care, UMC Utrecht, Utrecht, Netherlands
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