Impact of advance directive (AD) completion among patients with metastatic cancer treated at an academic medical center.

Abstract

114 Background: Between February and September 2013, AD documentation for oncology patients across Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC) increased from 36% to 48%. However, it remains unclear whether AD completion itself is associated with other indicators of quality care. Methods: Using the tumor registry and National Death Index patient data, we examined a cohort of deceased NCCC patients diagnosed with metastatic disease between April 1, 2011 and October 31, 2013. To account for unmeasured care provided outside of NCCC, only patients with at least two NCCC visits, one of which occurred within the last six months of life, were included. Individual patient electronic medical record data were then linked to the registry data and multivariable regression was performed to determine the effect of AD completion on end-of-life quality metrics. Results: The cohort consisted of 225 patients, 182 (81%) of whom had an advance directive on file and 43 (19%) who did not. There were no significant differences in the age, gender or cancer diagnosis between the two groups. Patients with an AD had shorter commutes to the medical center (mean 42 vs 58 minutes, p<0.01) and more visits with cancer center providers (median 11.5 vs. 4.0, p=0.03). Palliative Care consulted with 73% of patients with an AD, versus 28% of patients without an AD (p<0.01). Completion of an AD did not decrease the likelihood of hospital death (OR 0.90, 95% CI 0.33-2.49), intensive care unit (ICU) death (OR 0.83, 0.19-3.66), hospital admission in the last 30 days of life (OR 0.94, 0.40-2.21), or ICU admission in the last 30 days of life (OR 1.30, 0.37-4.55). Patients with an AD were twice as likely to receive hospice referrals (OR 2.04, 0.73-5.68) and 70% less likely to visit the emergency department in the last 30 days of life compared with patients without an AD on file (OR 0.28, 0.06-1.40), although these trends were not statistically significant. Conclusions: For patients with metastatic cancer, an advance directive was associated with increased use of palliative care, though not with other measures of quality care. In an attempt to improve the cancer care provided at the end of life, we must expand our strategies beyond the use of an AD.