End-of-life Treatment Preferences Research Articles

Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life.

Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.

End-of-life treatment preferences and advanced care planning among older adults

End-of-life treatment preferences (EOLTPs) refer to the amount of medical intervention an individual would wish to receive in a life-threatening scenario. This study aimed to investigate relationships between older adults’ EOLTPs and advance care planning (ACP). Using archival data from two interview surveys of community-dwelling older adults (study 1 n = 331, study 2 n = 338; age 60–102), results found that a desire for less end-of-life medical intervention was associated with greater EOL discussion with physicians. This relationship was explained by greater death preparation and younger age. Older adults may use ACP to limit unwanted medical interventions.

An Intervention in Congruence for End-of-Life Treatment Preference: A Randomized Trial.

There is a gap in family knowledge of their adolescents' end-of-life (EOL) treatment preferences. We tested the efficacy of Family Centered Advance Care Planning for Teens with Cancer (FACE-TC) pediatric advance care planning (to increase congruence in EOL treatment preferences. Adolescents with cancer/family dyads were randomized into a clinical trial from July 2016 to April 2019 at a 2:1 ratio: intervention (n = 83); control (n = 43) to either 3 weekly sessions of FACE-TC (Lyon Advance Care Planning Survey; Next Steps: Respecting Choices Interview; Five Wishes, advance directive) or treatment as usual (TAU). Statement of Treatment Preferences measured congruence. Adolescents' (n = 126) mean age was 16.9 years; 57% were female and 79% were White. FACE-TC dyads had greater overall agreement than TAU: high 34% vs 2%, moderate 52% vs 45%, low 14% vs 52%, and P < .0001. Significantly greater odds of congruence were found for FACE-TC dyads than TAU for 3 of 4 disease-specific scenarios: for example, "a long hospitalization with low chance of survival," 78% (57 of 73) vs 45% (19 of 42); odds ratio, 4.31 (95% confidence interval, 1.89-9.82). FACE-TC families were more likely to agree to stop some treatments. Intervention adolescents, 67% (48 of 73), wanted their families to do what is best at the time, whereas fewer TAU adolescents, 43% (18 of 42), gave families this leeway (P = .01). High-quality pediatric advance care planning enabled families to know their adolescents' EOL treatment preferences.

Me & My Wishes: Concordance of End-of-Life Preferences between Residents with Dementia, Family, and Staff.

Objective: Me & My Wishes involves videos of persons living with dementia talking about their end-of-life (EOL) care preferences. This study aimed to examine the concordance of EOL treatment and psychosocial preferences expressed by assisted living community and nursing home residents in these videos with family and staff knowledge of preferences. Design: Randomized wait-list control. Setting/Subjects: Assisted living and nursing home residents in the United States, and their family members and caregivers. Measurements: Five EOL treatment preferences (cardiopulmonary resuscitation or CPR, breathing machine, tube feeding, life support, and pain treatment) and four near EOL psychosocial preferences (having family at the bedside, engaging in faith practices such as prayer, having a pet at bedside, and engaging in activities such as being read to or listening to music) extracted from residents' videos and captured through family and staff surveys. Results: Thirty-six resident videos were shared with family (N = 50) and staff (N = 38) during care plan meetings. Concordance between residents' stated EOL treatment preferences and family and staff knowledge improved, with results showing a treatment effect at time of sharing the video (family: Beta = 0.21, p < 0.001; staff: Beta = 0.35, p < 0.001). Conclusion: Our findings indicate that sharing Me & My Wishes videos improved family and staff concordance of EOL psychosocial and treatment preferences for assisted living and nursing home residents living with dementia. Personalized videos conveying resident preferences can help informal and formal caregivers understand the resident as a person and foster concordant care. Clinical Trial Registration Number NCT03861429.

Social Determinants of Health May Predict End of Life Portable Orders for Life Sustaining Treatment Form Completion and Treatment Selections.

End of life (EOL) care planning is important for aging adults given the growing prevalence of chronic medical conditions in the US. The Portable Orders for Life Sustaining Treatment (POLST) program promotes communication between clinicians and patients with advanced illness about EOL treatment preferences. Despite growing resources for EOL care, utilization remains unequal based on social determinants of health (SDOH), including race, language, urbanization, and education. We evaluated the relationship between POLST form selections and completion rates and SDOH. Oregon POLST Registry and American Community Survey data from 2013 to 2017 were analyzed retrospectively. POLST form completion rates and selections, and various SDOH, including age, income, insurance status, urbanization, etc. were recorded. Data were merged based on ZIP codes and analyzed using χ2 or Wilcoxon-Mann-Whitney tests. Logistic regression was performed. 127,588 POLST forms from 319 ZIP codes were included. POLST form completion rates were highest among urban ZIP codes, and urban registrants more often selected CPR and full treatment. ZIP codes with higher incomes tended to select CPR. ZIP codes with higher rates of private insurance completed POLST forms, and selected CPR and full treatment more frequently. ZIP codes with higher rates of Bachelor's degrees (or higher) completed POLST forms and selected full treatment more frequently. Various SDOH-specifically, urbanization, insurance status, income level and educational level achieved-may influence POLST form completion rates and selections. The expanding socioeconomic diversity and growth of urban communities, highlight the need for broader access to EOL planning and POLST.

254 Nephrology and Palliative Care Collaboration to Elicit End of Life Treatment Preferences in Veterans With ESRD

254 Nephrology and Palliative Care Collaboration to Elicit End of Life Treatment Preferences in Veterans With ESRD

Me &amp; My Wishes Videos: Congruence of End-of-Life Preferences Between Residents With Dementia, Family, and Staff

Me & My Wishes are person-centered videos of long term care residents (ages 65-95) living with dementia discussing their preferences for care including end-of-life (EOL) medical intervention. We evaluated the congruence of six EOL treatment preferences between the residents’ personal videos, medical records (e.g. advance directive), and surveys of family (n= 49) and staff (n=37; 118 responses) knowledge of their preferences. Results were highly discordant. Treatments with the most discordance when comparing videos to comparison groups were IV fluids (medical record, 57.1%) and life support (family, 69.4%; staff, 82.2%). Residents reported EOL treatments were considered acceptable if they were temporary, would relieve suffering, or enabled a return to baseline health. These caveats may lead to discordance if they are not conveyed to family or staff. Our findings highlight the need for conversations among residents living with dementia and their caregivers to improve understanding, congruence and adherence of resident EOL preferences.

The development of an individual differences end-of-life treatment preferences scale

The purpose of this study was to create an individual differences measure of end-of-life treatment preferences (EOLTPs). Young adults (n = 427) and older adults (n = 333) completed a survey. Results found that hope of recovery was an important factor in whether individuals preferred a given medical intervention. A single factor explained the majority of the variance in EOLTPs, and EOLTPs were distinct from more general attitudes about medical care. Older adults preferred less end-of-life medical intervention compared to younger adults. Overall, the results of the study support the use of an individual differences approach to measuring EOLTPs.

Palliative Care Clinician Overestimation of Survival in Advanced Cancer: Disparities and Association With End-of-Life Care

ContextClinicians frequently overestimate survival time in serious illness. ObjectiveThe objective of this study was to understand the frequency of overestimation in palliative care (PC) and the relation with end-of-life (EOL) treatment. MethodsThis is a multisite cohort study of 230 hospitalized patients with advanced cancer who consulted with PC between 2013 and 2016. We asked the consulting PC clinician to make their “best guess” about the patients' “most likely survival time, assuming that their illnesses are allowed to take their natural course” (<24 hours; 24 hours to less than two weeks; two weeks to less than three months; three months to less than six months; six months or longer). We followed patients for up to six month for mortality and EOL treatment utilization. Patients completed a brief interviewer-facilitated questionnaire at study enrollment. ResultsMedian survival was 37 days (interquartile range: 12 days, 97 days) and 186/230 (81%) died during the follow-up period. Forty-one percent of clinicians' predictions were accurate. Among inaccurate prognoses, 85% were overestimates. Among those who died, overestimates were substantially associated with less hospice use (ORadj: 0.40; 95% CI: 0.16–0.99) and later hospice enrollment (within 72 hours of death ORadj: 0.33; 95% CI: 0.15–0.74). PC clinicians were substantially more likely to overestimate survival for patients who identified as Black or Latino compared to others (ORadj: 3.89; 95% CI: 1.64–9.22). EOL treatment preferences did not explain either of these findings. ConclusionOverestimation is common in PC, associated with lower hospice use and a potentially mutable source of racial/ethnic disparity in EOL care.

A randomized clinical trial of adolescents with HIV/AIDS: pediatric advance care planning

ABSTRACTThe objective of this study is to determine if pediatric advance care planning (pACP) increases adolescent/family congruence in end-of-life (EOL) treatment preferences longitudinally. Adolescents aged 14–21 years with HIV/AIDS and their families were randomized (N = 105 dyads) to three-60-minute sessions scheduled one week apart: either the pACP intervention (survey administered independently, facilitated conversation with adolescent and family present, completion of legal advance directive document with adolescent and family present) or an active control (developmental history, safety tips, nutrition and exercise education). This longitudinal, single-blinded, multi-site, randomized controlled trial was conducted in six pediatric hospital-based HIV-clinics, located in high HIV mortality cities. The Statement of Treatment Preferences measured adolescent/family congruence in EOL treatment preferences at immediately following the facilitated pACP conversation (Session 2), and at 3-month post-intervention. The mean age of adolescent participants was 18 years (range 14–21 years); 54% were male; and 93% were African-American. One-third had an AIDS diagnosis. Immediately post-intervention the Prevalence Adjusted Bias Adjusted Kappa showed substantial treatment preference agreement for pACP dyads compared to controls (High burden/low chance of survival, PABAK = 0.688 vs. 0.335; Functional impairment, PABAK = 0.687 vs. PABAK= 0.34; Mental impairment, PABKA = 0.717 vs. 0.341). Agreement to limit treatments was greater among intervention dyads than controls (High burden: 14.6% vs. 0%; Functional impairment = 22.9% vs. 4.4%; and Mental impairment: 12.5% vs. 4.4%). Overall treatment preference agreement among pACP dyads was high immediately post-intervention, but decreased over time. In contrast, treatment agreement among control dyads was low and remained low over time. As goals of care change over time with real experiences, additional pACP conversations are needed.

Longitudinal Analysis of HIV Adolescent/Surrogate Congruence on End of Life Treatment Preferences

To identify the longitudinal pattern of HIV positive adolescents/surrogates’ congruence on end-of-life treatment preferences in three HIV related bad outcome situations (high burden/low chance of survival, functional impairment, and mental impairment); and examine the effect of an ACP intervention on the pattern.

Abstract 13306: Advanced Care Planning in Persons Who Die From Heart Disease

Introduction: The unpredictable trajectory of persons dying from cardiovascular disease (CVD) may make planning for future care challenging. In order to target quality improvement (QI) efforts, it is necessary to identify factors associated with advanced care planning (ACPing) in CVD. Methods: The Health Retirement Survey (a nationally representative sample) provided data for a secondary data analysis of 1304 individuals’ ≥65 years of age that died of CVD from 2002-2012. Proxies of decedents reported ACPing activities (identifying a durable power of attorney for health care [DPOA_HC], completing a living will, or engaging in a conversation about care preferences at end of life (EoL). Demographic and clinical factors were also recorded. Results: Proxies reported 78% of decedents engaged in some level of ACPing (60% had a DPOA_HC, 56.5% had a conversation about EoL treatment preferences, and 47.3% completed a living will). In bivariate analysis, being older, female, Caucasian, widowed, dying at home/hospice/other, having higher income or education, and more symptoms were associated with any type of ACPing (chi-squared test p-value ranges between &lt;0.000 and 0.028). In the multivariate regression model, older age (OR=1.026, 95%CI [1.002, 1.052], p=0.037), Caucasian race (OR=1.754, 95%CI [1.126, 2.735], p=0.013), more education (‘high school grad’: OR=1.723, 95%CI [1.151, 2.580], p=0.008; ‘some college’: OR=2.659, 95% CI [1.451, 4.871], p=0.002; ‘college grad’: OR=3.404, 95%CI [1.710, 6.774], p&lt;0.000), higher income (‘$10,001-$88,000’: OR=1.670, 95%CI [1.000, 2.791], p=0.050; ‘&gt;$88,000’: OR=2.012, 95%CI [1.150,3.520], p=0.014), and more symptom burden (OR=1.350, 95%CI [1.217, 1.498], p&lt;0.000) were associated with any type of ACPing. Conclusions: The majority of individuals dying of CVD participate in ACPing. QI efforts to improve ACPing should target non-Caucasian individuals with less education, less income, younger age, and lower symptom burden.

End-of-Life Discussions with Older Adults.

To determine the prevalence of end-of-life (EOL) conversations with older adults. National Health and Aging Trends Study (NHATS), a prospective, longitudinal survey of Medicare beneficiaries. Nationally representative. A sample drawn from Wave 2 of the NHATS. The main outcome was the report of an EOL planning discussion, based upon the participant's response to the question "Have you talked to anyone about the types of medical treatment you would want or not want if you became seriously ill in the future?" Sixty-one percent of the sample (n = 1,993 individuals, weighted n = 11,123,910) responded that they had discussed EOL treatment preferences with someone. In multivariate regression, factors associated with reporting an EOL discussion included being younger (adjusted odds ratio (AOR) = 1.70, 95% confidence interval (CI) = 1.17-2.47), having more education (high school degree: AOR = 1.45, 95% CI = 1.02-2.07; some college: AOR = 2.03, 95% CI = 1.40-2.95), and having multiple chronic conditions (AOR = 1.25, 95% CI = 1.01-1.55). Black race was associated with lower odds of reporting a discussion (AOR = 0.46, 95% CI = 0.33-0.65). Forty percent of a nationally representative sample of Medicare beneficiaries had not discussed their preferences regarding EOL medical treatment. Promoting these conversations in clinical and nonclinical settings will be important to ensure that health care is delivered to individuals in a person-centered manner.

Longitudinal Randomized Controlled Trial of Advance Care Planning for Teens: Religiousness and End of Life Treatment Preferences

Purpose: One pilot study among HIV positive adolescents indicated spirituality, as measured by the FACIT-SP, was not associated with the decision to use intensive life-prolonging treatments. Yet adult studies indicate the opposite (Phelps, 2009), particularly for African-Americans (Johnston, et al., 2005). The purpose of this study is to examine the relationship between religiousness in adolescents living with HIV and their end of life treatment preferences in a longitudinal randomized clinical trial of an advance care planning intervention. Hypothesis: high religiousness at baseline will interact with an advance care planning intervention to increase the likelihood of choosing to continue all treatments across end of life situations at 3 month post-intervention follow-up. Methods: Adolescents ( 14, <21 years of age, N1⁄4107) were randomized to either the FAmily-CEntered Advance Care Planning intervention or to the Healthy Living Control condition. Religiousness was assessed at baseline through the Brief Multidimensional Measurement of Religiousness/Spirituality (BMMRS; Fetzer Institute/NIA 1999). The Statement of Treatment Preferences measured treatment preferences in three HIV related bad outcome situations (SOTP; Hammes & Briggs, 2008) at 3 month post-intervention. Analysis included 85 adolescents who completed 3 month follow-up, using latent profile analysis (LPA) of models of religiousness. The logistic procedure for analysis of maximum likelihood estimates was then used to test for direct intervention effects and intervention interactionwith latent profiles of religiousness on preference outcomes. Fisher’s exact test for binary relationship and logistic model were then used. Results: Adolescents were: 51% female, 72% perinatally-acquired HIV; mean age 18 years old; 93% African-American or black; 27% advanced HIV. LPA yielded four profiles: Profile 1 and 3 were religious while Profile 2 and 4 were not. There was one significant relationship of continue treatment in Situation 1 and religious profile. Patients in Religious Profile 1 and Profile 3 (higher religiousness) were more likely to choose to continue all treatments in Situation 1 (prolonged hospital stay with multiple interventions) than patients in Religious Profile 2 and Profile 4 (low religiousness) (b1⁄43.00-0.731⁄42.27, p-value1⁄40.0137). The main effect of the advance care planning intervention was to significantly decrease the choice to continue all treatments in Situation 1 (Maximum likelihood estimate -2.3286, p1⁄40.0276). In the control group there was no interaction of religiousness with treatment preferences. There were no significant effects for age, gender, race or mode of transmission. Conclusions: The main effect of the intervention, to decrease the choice to continue all treatments in Situation 1, disappeared if the adolescent had strong religiousness. This is similar to adult studies that show religiousness as a mediator of end of life decisions. Religious HIV positive adolescents who were randomized to the intervention were willing to endure long hospitalizations compared to their nonreligious peers. Sources of Support:

FAmily CEntered (FACE) advance care planning: Study design and methods for a patient-centered communication and decision-making intervention for patients with HIV/AIDS and their surrogate decision-makers

Although the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has become a chronic illness, disease-specific advance care planning has not yet been evaluated for the palliative care needs of adults with HIV/AIDS. This prospective, longitudinal, randomized, two-arm controlled clinical trial aims to test the efficacy of FAmily CEntered advance care planning among adults living with AIDS and/or HIV with co-morbidities on congruence in treatment preferences, healthcare utilization, and quality of life. The FAmily CEntered intervention arm is two face-to-face sessions with a trained, certified facilitator: Session 1) Disease-Specific Advance Care Planning Respecting Choices Interview; Session 2) Completion of advance directive. The Healthy Living Control arm is: Session 1) Developmental/Relationship History; Session 2) Nutrition. Follow-up data will be collected at 3, 6, 12, and 18 months post-intervention. A total of 288 patient/surrogate dyads will be enrolled from five hospital-based, out-patient clinics in Washington, District of Columbia. Participants will be HIV positive and ≥21years of age; surrogates will be ≥18years of age. Exclusion criteria are homicidality, suicidality, psychosis, and impaired cognitive functioning. We hypothesize that this intervention will enhance patient-centered communication with a surrogate decision-maker about end of life treatment preferences over time, enhance patient quality of life and decrease health care utilization. We further hypothesize that this intervention will decrease health disparities for Blacks in completion of advance directives. If proposed aims are achieved, the benefits of palliative care, particularly increased treatment preferences about end-of-life care and enhanced quality of life, will be extended to people living with AIDS.

Racial/ethnic differences in end-of-life (EoL) treatment preferences: The role of religious beliefs about care.

6529 Background: Racial/ethnic minorities and patients who turn to religion to cope receive more aggressive EOL care. Beliefs underlying these associations are unknown. Methods: Coping with Cancer is an ongoing, multi-site, NCI-funded study examining factors influencing racial/ethnic EoL disparities. From 11/2010-10/2012, 133 advanced cancer patients underwent baseline interviews, including 7 items assessing religious beliefs about EoL care (RBEC). Univariate analyses assessed racial/ethnic differences in RBEC and EoL treatment preferences. Multivariable analyses (MVA) modeled mean RBEC score as a function of race/ethnicity, controlling for confounders, and assessed the relationship of race/ethnicity and RBEC to treatment preferences. Results: Religious beliefs about EoL care are common and more often held by racial/ethnic minorities (Table); racial/ethnic differences persisted in MVA (p&lt;.0001). Black patients were more likely than Whites to prefer aggressive EOL care (OR=5.03, p=.02), whereas Latino’s EOL preferences did not differ from Whites (p=.87). In MVA including race and RBEC score, Black race was not related to EOL care preferences (OR 1.61, p=0.55), whereas greater RBEC score was associated with greater preference for aggressive care (OR 2.48, p=0.003). Conclusions: Religious beliefs about EoL care are common and significantly more so among racial/ethnic minorities. Preliminary data suggest these beliefs mediate the relationship between race/ethnicity and EoL treatment preferences. [Table: see text]

Nurses' preferred end‐of‐life treatment choices in five countries

Previous research has focused on physician's perspectives of end-of-life (EOL) decision making as well as patient and family EOL decision making. There is a lack of research pertaining to the EOL treatment preferences of nurses and especially nurses working in a variety of care settings. The aim of this study was to compare nurses' EOL treatment preferences in Hong Kong, Ireland, Israel, Italy and the USA. A comparative descriptive design was used with a convenience sample of nurses (n = 1089). A survey questionnaire using EOL hypothetical clinical case scenarios was used to collect data between June 2011 and July 2012. Nurses in every country consistently chose a more aggressive option for patients than for themselves or for a parent. The treatment preferences of nurses varied from country to country. Lack of knowledge of patients' wishes and duty of care were the main influencing factors on treatment preferences. The study was limited to the hypothetical nature of the scenarios; however, the study highlights numerous future research questions. This study is the first to examine and compare nurses' preferred EOL treatment choices in five countries from three different continents. The findings of this study raise several important questions for healthcare researchers, for policy development, and highlight the need for further international collaboration.

Patient Values and Preferences for End-of-Life Treatments: Are Values Better Predictors Than a Living Will?

Advance care planning is widely considered important for good treatment decision making. Patient values have been proposed as superior to standard living wills as guides to end-of-life (EOL) care decisions on behalf of decisionally incapacitated patients. Little research has examined whether values outperform living wills as predictors of treatment preferences. The study aimed to test whether patient values are associated with treatment preferences, compare values and preferences to responses from a standard living will, and determine whether some values are better predictors than others. Community-dwelling elderly men and women (n=304) were interviewed in their homes by telephone. The interview consisted of an eight-item EOL values scale, a standard living will question, preferences for four life-prolonging treatments in each of six scenarios, and sociodemographic questions. Principal components analysis of the EOL values revealed two factors: (1) dignity, pain management, and reluctance to burden others; and (2) religiosity and desire for longevity and following family wishes. In regression analyses, stronger preferences for life-prolonging treatments were correlated with higher scores on factor 1 and lower scores on factor 2. But when living will responses were also entered into the regression model, only religiosity, longevity, and following family wishes predicted treatment preferences independently of the living will responses. Providing better guidance than a living will in determining a patient's EOL treatment preferences are (1) knowledge about a patient's religiosity, (2) patient's wishes for longevity, and (3) patient's wishes for following family preferences. Wishes for dignity and pain management and reluctance to burden others do not offer better guidance than a living will.

Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle (FACE): Design and methods

As life expectancy increases for adolescents ever diagnosed with AIDS due to treatment advances, the optimum timing of advance care planning is unclear. Left unprepared for end-of-life (EOL) decisions, families may encounter miscommunication and disagreements, resulting in families being charged with neglect, court battles and even legislative intervention. Advanced care planning (ACP) is a valuable tool rarely used with adolescents. The Longitudinal Pediatric Palliative Care: Quality of Life & Spiritual Struggle study is a two-arm, randomized controlled trial assessing the effectiveness of a disease specific FAmily CEntered (FACE) advanced care planning intervention model among adolescents diagnosed with AIDS, aimed at relieving psychological, spiritual, and physical suffering, while maximizing quality of life through facilitated conversations about ACP. Participants will include 130 eligible dyads (adolescent and family decision-maker) from four urban cities in the United States, randomized to either the FACE intervention or a Healthy Living Control. Three 60-minute sessions will be conducted at weekly intervals. The dyads will be assessed at baseline as well as 3-, 6-, 12-, and 18-month post-intervention. The primary outcome measures will be in congruence with EOL treatment preferences, decisional conflict, and quality of communication. The mediating and moderating effects of threat appraisal, HAART adherence, and spiritual struggle on the relationships among FACE and quality of life and hospitalization/dialysis use will also be assessed. This study will be the first longitudinal study of an AIDS-specific model of ACP with adolescents. If successful, this intervention could quickly translate into clinical practice.

Anxiety disorders in advanced cancer patients

: The authors explored associations between anxiety disorders and advanced cancer patients' physical performance status, physician-patient relationships, end-of-life (EOL) treatment preferences and outcomes, and quality of death. : The Coping with Cancer study was a National Cancer Institute/National Institute of Mental Health-sponsored, prospective, longitudinal, multicenter cohort study of patients with advanced cancer. Six hundred thirty-five patients completed the anxiety disorders module of the Structured Clinical Interview for the Diagnostic Statistical Manual IV. The results were compared with patients' baseline physical performance status, treatment preferences, perceptions of the physician-patient relationship, and advance care planning (ACP). : Approximately 7.6% of patients met criteria for an anxiety disorder. Patients who were diagnosed with an anxiety disorder were more likely to be women and younger and to have a worse physical performance status. Although there were no significant differences in patients' EOL treatment preferences or care, ACP, hospice enrollment, or patients' location of death, there were significant differences in how patients with anxiety disorders perceived the physician-patient relationship. Patients with anxiety disorders had less trust in their physicians, felt less comfortable asking questions about their health, and felt less likely to understand the clinical information that their physicians presented. They also were more likely to believe that their physicians would offer them futile therapies and would not adequately control their symptoms. : Women, patients who were more physically impaired, and younger patients with advanced cancer were more likely to meet criteria for an anxiety disorder. Patients with advanced cancer who had an anxiety disorder were more likely to experience greater challenges to the physician-patient relationship. Cancer 2010. (c) 2010 American Cancer Society.