Accurate prognostic awareness and preference states influence the concordance between terminally ill cancer patients’ states of preferred and received life-sustaining treatments in the last 6 months of life

• Published in: Palliative medicine 2019-09, Vol.33 (8), p.1069-1079
• Main Authors: Wen, Fur-Hsing, Chen, Jen-Shi, Chang, Wen-Cheng, Chou, Wen-Chi, Hsieh, Chia-Hsun, Tang, Siew Tzuh
• Format: Article
• Language: English
• Subjects: Aged; Awareness; Cancer; Cardiopulmonary resuscitation; Confidence intervals; Death & dying; End of life decisions; Euthanasia; Female; Humans; Intensive care; Life Support Care; Longitudinal Studies; Male; Markov Chains; Massage; Mechanical ventilation; Medical prognosis; Middle Aged; Neoplasms - pathology; Patient Preference; Patients; Prognosis; Psychological distress; Taiwan; Terminal Care; Terminal illnesses; Terminally Ill; Treatment preferences; Ventilation
• ISSN: 0269-2163; 1477-030X
• DOI: 10.1177/0269216319853488

Background: Factors facilitating/hindering concordance between preferred and received life-sustaining treatments may be distorted if preferences and predictors are measured long before death. Aim: To examine factors facilitating/hindering concordance between cancer patients’ preferred and received life-sustaining-treatment states in their last 6 months. Design: Longitudinal, observational design. Setting/participants: States of preferred and received life-sustaining treatments (cardio-pulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, and nasogastric tube feeding) were examined in 218 Taiwanese cancer patients by a latent transition model with hidden Markov modeling. Multivariate logistic regression modeling was used to examine factors facilitating/hindering concordance between preferred and received life-sustaining-treatment states. Results: Concordance between preferred and received life-sustaining-treatment states was poor (40.8%, kappa value (95% confidence interval): 0.05 [–0.03, 0.14]). Patients who accurately understood their prognosis and preferred comfort care were significantly more likely to receive preferred life-sustaining treatments before death than those who did not know their prognosis but wanted to know, those who were uniformly uncertain about what life-sustaining treatments they preferred to receive, and those who preferred nutritional support but declined other life-sustaining treatments. Patient age, physician–patient end-of-life-care discussions, symptom distress, and functional dependence were not associated with concordance between preferred and received life-sustaining-treatment states. Conclusion: Prognostic awareness and preferred states of life-sustaining treatments were significantly associated with concordance between preferred and received life-sustaining-treatment states. Personalized interventions should be developed to cultivate terminally ill cancer patients’ accurate prognostic awareness, allowing them to formulate realistic life-sustaining-treatment preferences and facilitating their receiving value-concordant end-of-life care.