- 1.Measure the overall relationship between advance care planning and end-of-life care outcomes among patients with cancer.
- 2.Distinguish among which individuals and in which contexts the relationship between advance care planning and the care received at the end-of-life differs for patients with cancer.
Original Research Background and Research Objectives
Advance care planning (ACP) is a potentially important intervention in promoting high-quality end-of-life cancer care, but the empirical evidence of this relationship is mixed. This meta-analysis estimated the overall effect of ACP on end-of-life care outcomes among patients with cancer and explored moderators of this relationship.
This meta-analysis followed PRISMA guidelines and was registered with PROSPERO (CRD42020146692). Six databases were searched using ACP and cancer terminology. Two investigators conducted article selection and data abstraction.
Data Extraction and Synthesis
Meta-analyses were run for two global outcomes (aggressive and comfort-focused end-of-life care), and individual outcomes when a minimum of 10 effect sizes were reported. The overall effect size was computed in log odds scale and back-transformed to the odds ratio.
Of 6,682 studies, 33 met criteria. These included 135,878 participants and 75 effect sizes (53 aggressive, 22 comfort-focused). Studies were primarily observational (52%), from the United States (79%), and had moderate risk of bias assessments (67%). There was not sufficient evidence of publication bias. Overall, ACP was associated with reduced odds of aggressive (OR = 0.83, 95% CI: 0.70, 0.98) and increased odds of comfort-focused (OR = 1.89, 95% CI: 1.47, 2.44) end-of-life care. Significant moderating effects were detected—a diminished protective effect of ACP against aggressive end-of-life care among samples with increasing proportions of males and an enhanced promotive effect on comfort-focused end-of-life care in observational versus intervention studies. Among individual outcomes, chemotherapy (OR = 1, 95% CI: 0.72, 1.39) and hospital death (OR = 0.78, 95% CI: 0.5, 1.21) were not significantly affected by ACP.
Conclusion and Implications for Practice, Policy, or Research
These findings provide an evidence base for the value of ACP in end-of-life care among patients with cancer and a catalyst for enhancing ACP engagement in this population, which may require personalized approaches and embedding ACP in broader clinical processes to augment outcomes.
© 2021 Published by Elsevier Inc.