A prospective cohort study of stability in preference for place of death among patients with stage IV cancer.

Abstract

e24148 Background: Advanced care planning (ACP) involves discussion and documentation of patients’ care preferences including their preference for place of death. This process assumes that patients’ preference will not change over time; yet evidence for this is inconclusive. The primary aim of this study was to test whether patient preference for place of death changes over time and to identify factors associated with this change. We also assessed whether patients who do not change their preference for place of death during the study duration have greater congruence between actual and baseline preference for place of death. Methods: As part of an ongoing cohort study, we surveyed 466 advanced cancer patients every 6 months in Singapore for a period of two years. We asked patients their preference for place of death (home/ institution/ unclear). We assessed proportion of patients who changed their preference from baseline and at every time point. We ran univariable and multivariable multinomial logistic regression models to assess the association between change in preference for place of death and patient socio-demographics (gender, race, education, housing, marital status) as well as time varying variables (quality of life (Functional Assessment of Cancer Therapy- General), pain severity (Brief Pain Inventory), psychological distress (Hospital Anxiety and Depression Scale), any intervening hospitalization). We used a logistic regression model to assess if no change in preference during the study period was associated with congruence between actual and baseline preference for place of death. Results: More than a quarter of patients changed their preference for place of death every 6 months with 55% changing their preference at least once within 2 years. There was no clear trend in direction of change in preference. Patients who were psychologically distressed at the time of survey had a greater relative risk of changing their preferred place of death to home (Relative Risk Ratio (RRR) 1.81; 95% Confidence Interval (CI): 1.16-2.82) and to institution (RRR 2.00; 95% CI: 1.17-3.42) relative to no change in preference. Having no change in preference for place of death during the study period was not associated with congruence between actual and baseline preference for place of death. Conclusions: The study provides evidence of instability in advanced cancer patients’ preference for place of death. It calls into question the validity of patient preference for place of death recorded on ACP documents and suggests that we should regularly re-evaluate these documents.