Health Care Proxy Research Articles

Feasibility of Advance Care Planning in Primary Care for Homeless Adults.

Objectives: As the homeless population ages, it is imperative to improve access to advance care planning (ACP) and document preferences in case medical decision-making capacity is lost. Methods: We implemented an ACP Project to discuss and document advance care plans with all patients aged 45 and older who received primary care at our adult Homeless Program clinics. Results: Over 14 months, ACP was discussed with 48% (n = 138) of the population and health care proxy (HCP) appointment with 91% (n = 125) of these patients. Most (62%; n = 77) appointed a HCP from personal relationships, though a significant minority (38%; n = 48) could not and were considered "surrogateless." End-of-life preferences varied. Approximately 20% of patients wanted to defer to a surrogate for each decision. Discussion: ACP is feasible in primary care for adults who have experienced homelessness and should be incorporated into routine care.

What Joanna Would Have Wanted.

To help health care proxies with end-of-life decisions, ask about patients' former selves.

Demonstrating the impact of POLST forms on hospital care requires information not contained in state registries.

BackgroundPhysician Orders for Life-Sustaining Treatment (POLST) programs have expanded rapidly, but evaluating their impact on hospital care is challenging.ObjectivesTo demonstrate how careful study design can reveal POLST’s impact at hospital admission and why analyses of state registry data are unlikely to capture POLST’s effects.DesignProspective cohort study.Setting and participantsAdult in-patients with Do Not Intubate and/or Do Not Resuscitate (DNR/I) orders in the electronic medical record at the time of discharge from Johns Hopkins Hospital over 18 months. For patients with unplanned readmissions within 30 days, records were reviewed to determine if a Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was presented and for the time from readmission to a DNR/I order in the EMR. Analyses were stratified by whether patients could communicate or were accompanied by a proxy at readmission.ResultsAmong 1,507 patients with DNR/I orders at discharge, 124 (8%) had unplanned readmissions, 112 (90%) could communicate or were accompanied by a proxy at readmission, and 12 (10%) could not communicate and were unaccompanied. For patients who were unaccompanied and could not communicate, MOLST significantly decreased the median time from readmission to DNR/I order (1.2 vs 27.1 hours, P = .001), but this association was greatly attenuated among patients who could communicate or were accompanied by a proxy (16.4 vs 25.4 hours P = .10).ConclusionAmong patients who wanted to avoid intubation and/or CPR, MOLST forms were protective when the patient was unaccompanied by a healthcare proxy at admission and could not communicate. Fewer than 10% of patients met these criteria during unplanned readmissions, and state registry data does not allow this sub-population to be identified.

Improving Preoperative Completion of Advanced Care Planning Documents in Patients With Expected Postoperative Intensive Care Unit Stay.

Directed discussion about advanced care planning in the preoperative setting is often lacking. We implemented an educational intervention pilot to increase the number of high-risk patients who have health care proxy and advanced directives documents completed. We developed a novel short video describing the advanced care planning process and the intensive care setting, encouraging patients to have conversations about advanced care planning. Survey results showed that majority of patients felt the intervention increased their knowledge about advanced care planning (65%-70%) and that the video raised some topics worth discussing with family and health care providers. This intervention is scalable and could improve documentation and quality of care.

Choice of and comfort with health care proxy among older adults: Hierarchical compensation and perceived similarity in values

The purpose of this study was to investigate choice of and comfort with health care proxy among older adults (N = 240). Results indicated that choice of proxy follows a hierarchical compensation model. Perceived similarity regarding end-of-life preferences and political views were not associated with comfort with proxy; however, perceived similarity with regards to religious values was associated with comfort with proxy. Attempts to promote advance care planning and advance directives may benefit from emphasizing individuals’ choice and autonomy but also their opportunity to designate a health care proxy who they feel represents their religious values.

Improving person-centered communication of goals, proxy, and advance directives in older patients with advanced cancer: Secondary analysis from a University of Rochester NCI Community Oncology Research Program (NCORP) cluster randomized controlled trial (CRCT).

11523 Background: Quality person-centered care relies on effective communication between the clinical team and the patient/caregiver eliciting goals and discussing wishes. In a PCORI- and NCI-funded CRCT, we found that providing community-based oncologists with geriatric assessment-guided recommendations led to more and higher quality discussions of age-related issues for older patients with advanced cancer. In this secondary analysis, we assessed whether specific recommendations to oncologists to discuss patient goals, proxy and advance directives resulted in increased communication about these topics. Methods: Patients aged 70+ with advanced solid tumors or lymphoma and at least one impaired geriatric domain (e.g., function, cognition) were enrolled (URCC 13070; PI: Mohile). Oncology practices were randomized to the intervention (oncologists received recommendations to elicit goals and discuss wishes) or usual care. The clinic visit after the oncologist received recommendations was recorded and transcribed; two blinded coders evaluated the transcripts for discussion of the specific topic areas recommended in the intervention. Between arm differences were compared using generalized linear models controlling for practice cluster. Results: From 2014-17, 528 patients (284 intervention) provided transcripts from 31 practices (mean age = 77, range 70-96 years; 49% female; mixed cancer diagnoses). Topics related to patient goals, proxy and advance directive wishes were more often discussed in the intervention arm (goals of care preferences: 9 vs 2%, p = .02, treatment goals: 35 vs 20%. p = .04, elicit caregiver input: 28 vs 3%. p < .01, assess values and goals: 25 vs 7%, p = .07, health care proxy: 40 vs 1%, p = .004, advance directive: 25 vs 1%, p = .002). Conclusions: In this community-based study of older adults providing recommendations to oncologists to discuss specific topics resulted in increased person-centered discussions with patients and caregivers about goals, proxy and advance directive wishes. However, the content areas were discussed in less than half of all visits. Clinical trial information: NCT02107443.

Survey to evaluate quality of cancer patient care: A questionnaire based analysis in a tertiary hospital.

e18320 Background: As the burden of cancer is on the rise, there is a need to understand the logistics in caring for cancer patients. Internists and nurses are integral part of cancer care team, alongside oncologists. Our aim was to assess their knowledge, attitude and practice in order to identify areas of strength and limitation to help devise opportunities to enhance care. Methods: A close ended cross-sectional survey was conducted among internal medicine physicians, residents and nurses. We developed 36 questions broadly based on cancer-care and distributed them randomly. Additionally, subjects were asked to list factors limiting their ability to provide effective care. We semi quantitatively graded the depth of awareness amongst participants. A total of 95 health care providers were included in the final analysis. Results: Only 62% of participants were accurate in knowledge based questions. About 57% believed all cancer patients benefit from less aggressive treatment and considered chemotherapy side-effects to be the most common cause of hospitalization. Total of 94% reported effective care coordination by visiting nurses, primary care providers in outpatient settings decrease readmissions. Seventy percent thought a dedicated inpatient service run by Oncologists would be better for cancer patient care, with 96% preferring co-management. Around 80% felt they were better able to manage decompensated heart failure and fulminant liver disease than oncological emergencies like neutropenic fever. All the attendings (100%) were comfortable discussing new cancer diagnosis compared to 65% residents and 60% nurses. However 58% of them would like the health care proxy to be involved in all goals of care decisions, irrespective of patient’s capacity. Conclusions: Surprisingly, the baseline knowledge about cancer-care is suboptimal and there is a significant gap in expected versus real cancer-care delivery. Most commonly encountered factors hindering patient-care were lack of awareness of cancer illness trajectories and unclear goals of care with inter-provider disparities/gaps in understanding them. Initiatives such as targeted education, shared care plan and engaging patients at every step is crucial.

A new model of care for patients with central nervous system cancers.

e18029 Background: Patients (pts) with primary or metastatic central nervous system (CNS) cancers often have multiple physical, psychosocial, and spiritual needs. Neurological impairments can transform relationship dynamics as loved ones become caregivers. These issues are difficult to address within a single outpatient oncology clinic. Methods: The Neurological Multidisciplinary Care Clinic (MdCC) at Memorial Sloan Kettering Cancer Center was a pilot study from 08/2017 to 01/2019 to foster a new model of care for complex pts with CNS cancers to identify and address their needs. The MdCC team, comprised of a neurologist, nurse, physiatrist, physical therapist, social worker(SW), case manager(CM), dietitian(RD), and chaplain. During a 3-hour visit, MdCC providers saw each pt/caregiver. Since 11/2017 participants completed validated surveys on unmet needs, financial strain, and home equipment prior to their visit and satisfaction surveys afterward. Descriptive statistics were used to analyze results. Results: Seventy-six pts were seen: 37 were female, median age 60. Of these 76 pts, 63 had primary CNS cancers; glioblastoma (51%) and high-grade glioma (HGG) (29%). Fifty-five were receiving cancer-directed therapy at the time of MdCC. Over 70% had never seen a SW, CM, RD, or physiatrist prior to MdCC. Pts’ most commonly reported need was “not being able to do the things I used to do”; for caregivers it was “I need my partner to have an ongoing CM.” Seventy-four pts (97%) received symptom management recommendations. Prognosis/coping with cancer was discussed with 70 (92%) which increased signed health care proxy forms by 11% and DNR orders by 3%. New/updated physical therapy was ordered for 48 pts (61%), orthotics for 8 (10%), and new equipment for 12 (15%). Five pts were referred to a food assistance program. Forty-five pts completed a satisfaction survey; of these, 96% were highly satisfied, and would recommend MdCC to others. Conclusions: Pts’/caregivers’ unmet needs were effectively identified and addressed in this new model, and an emphasis on supportive and coordinated care contributed to high pt/caregiver satisfaction. We therefore propose to offer this clinic for all pts with HGG to improve pts’ well-being, quality of care, and increase pt/caregiver satisfaction.

Death and Dying: A Nursing Focus on the Care of the Patient

The role of the nurse is often associated with healing and helping bring people back to health. While this is a large aspect of the nursing profession, the nurse also cares for patients who are dying. The care delivered at this time revolves around the comfort of the patient, as well as ensuring that all of the patient's needs are met, including any cultural or spiritual needs. In order for the care of the patient to transition from curative to comfort measures, it is necessary for a diagnosis of dying to be made. This diagnosis should then be communicated with the patient and family. When the diagnosis of death is not communicated in a timely manner, it has been found that the patient's do not receive quality end of life care. This diagnosis surpasses all other diagnoses and shifts the focus towards the comfort and well-being of the patient. Care at the end of life includes pain management, discontinuation of routine vital signs and laboratory tests and coordinating care with other professionals to ensure the best quality care is being offered. Since the end of life is a new experience for most, it is important that the nurse informs the patient and the family of interventions that will occur and all resources available to them. Palliative care is a resource that can be implemented along curative measures at any stage of a disease, which assists the patient with pain and symptom management. As the disease course continues and the patient's life expectancy is less than six months, hospice care is a resource that should be offered. The nurse, along with the rest of the care team, should ensure that these resources, along with legal documents such as advanced directives or healthcare proxy forms are available to the patient. At the end of life, the nurse is on the front lines to ensure that the patient is receiving the best quality care possible. This is done by communicating and listening to the patient and developing a therapeutic relationship with them.

Advance care planning dispositions: the relationship between knowledge and perception

BackgroundLegal dispositions for advance care planning (ACP) are available but used by a minority of older adults in Switzerland. Some studies found that knowledge of and perception of those dispositions are positively associated with their higher usage. The objective of the present study is to test the hypothesis of an association between increased knowledge of ACP dispositions and a more positive perception of them.MethodsData collected in 2014 among 2125 Swiss community-dwellers aged 71 to 80 of the Lausanne cohort 65+ (Lc65+), a population-based longitudinal study on aging and frailty. Data collection was conducted through a questionnaire on knowledge, use and perception of lasting power of attorney, advance directives and designation of a health care proxy. Covariables were extracted from the Lc65+ database. Bivariable and multivariable regression analyses assessed the association between level of knowledge and perception.ResultsHalf the participants did not know about legal dispositions for ACP; filing rates were 14% for advance directives, 11% for health care proxy and 6% for lasting power of attorney. Level of knowledge about the dispositions was associated with a more positive perception of them, even when adjusting for confounding factors.ConclusionAlthough the direction of the association’s causality needs more investigation, results indicate that better knowledge on ACP dispositions could improve the perception older people have of them. Communication on dispositions should take into account individual knowledge levels and address commonly enunciated barriers that seem to diminish with increased knowledge.

Understanding Underuse of Advance Care Planning Among a Cohort of African American Patients With Advanced Cancer: Formative Research That Examines Gaps in Intent to Discuss Options for Care.

Advance care planning (ACP), palliative care (PC), and hospice are often underutilized by African Americans (AAs). This study assessed the impact of stage of intent to discuss ACP options as key potential barriers. We examined intent to discuss completion of ACP, PC, and hospice among 22 AA patients with cancer admitted to a local safety net hospital. Participants were asked about intent to discuss an advanced directive or living will (AD/LW), medical power of attorney (MPOA), PC, and hospice with their doctors. Intent to discuss these ACP components was based on the transtheoretical model. Electronic health records were reviewed at various intervals to assess completion of ACP behaviors and survival. Participants had colorectal (33%), breast (44%), and lung (23%) cancer, and 82% had stage III/IV disease. Low percentages of patients were in the precontemplation stage for AD/LW completion (4.6%), MPOA completion (13.6%), and PC discussions (27.2%), but 77.2% were in the precontemplation stage for hospice discussions. At 1 year, only 5% completed an AD/LW, 36.4% appointed an MPOA, 42.9% were referred to PC, and 12.5% were referred to hospice. More than half (54.6%) were deceased by the study's conclusion. Most (81%) of these died within 6 months of their baseline study assessment. Despite being hospitalized with advanced cancer and having poor prognosis, intent to discuss ACP options, PC, and hospice in this population was variable, and completion of these activities was low. This formative research is needed to develop education and counseling interventions for this high-risk, vulnerable population.

SAT-503 A Rare Case of Hypercalcemia Due to PTH Secreting Lung Adenocarcinoma

Introduction: Hypercalcemia can be present in up to 20% of malignancies. The majority are caused by humoral hypercalcemia of malignancy, mediated by secretion of PTHrP, typically by squamous cell carcinomas. Other etiologies of hypercalcemia in malignancy include local osteolysis, and increased production of 1,25(OH)2D. In rare cases, hypercalcemia can be caused by secretion of PTH by tumors. Clinical Case: A 60-year-old man with metastatic lung adenocarcinoma presented with altered mental status and was noted to have hypercalcemia to 19.2 mg/dL (reference range, 8.5-10.1). Imaging revealed a 12.0 cm right mediastinal soft tissue mass. He was initially treated with isotonic saline, calcitonin, and zolendronic acid. PTH was elevated to 594 pg/mL (reference range, 14-72), 25OHD was low at 13.2 ng/mL (reference range, 30-100), and PTHrP was normal at 22 pg/mL (reference range, 14-27). Serum calcium reached a nadir of 9.3 mg/dL (reference range, 8.5-10.1). During the course of hospitalization, serum calcium began to rise despite repeated infusions of zolendronic acid. Given inappropriately elevated PTH, hypercalcemia, and normal PTHrP, it was assessed that primary hyperparathyroidism may be the cause of hypercalcemia, and potentially treatable with parathyroid surgery. Endocrine surgery was consulted, and recommended a sestamibi scan, which failed to reveal parathyroid adenomas; however, there was significant uptake over the right upper lung region, left axillary region and bony structures, spatially concordant with the known malignancy. Calcium continued to rise, at which time the health care proxy decided against any further interventions. The patient expired on day 30. Conclusion: PTHrP causes hypercalcemia via similar mechanisms to PTH. In this patient, primary hyperparathyroidism was considered unlikely as the sestamibi scan did not reveal any evidence of parathyroid adenomas; instead, there was increased uptake over the patient’s lung mass, axillary lymph nodes, and metastatic bone lesions. There are known case reports of PTH secreting tumors, which were demonstrated on both sestamibi and immunohistochemistry for intact PTH on tumor tissue. PTH secreting tumors, whilst rare, should be considered in patients with elevated PTH, normal PTHrP levels, and no evidence of primary hyperparathyroidism. Sestamibi scan should be considered as a modality to help diagnose PTH secreting tumors if suspected.

Substance Use Among Older Adults: Ethical Issues.

Substance Use Among Older Adults: Ethical Issues.

Young Adult Knowledge and Readiness to Engage in Advance Care Planning Behaviors.

Although advance care planning (ACP) has increased in importance and discussion, little is known about young adults' engagement in ACP. The purpose of this study was to identify associations among college-age students' characteristics, knowledge of ACP, and readiness to engage in ACP-related behaviors. One hundred forty-seven students at the University of Texas at Austin (aged 18-26 years) participated in an online survey regarding ACP knowledge, perceptions, and behavior engagement. Although 98% of the students had no advance directive, 85% rated themselves as "pro" ACP. Regarding ACP behaviors, at least 83% of participants had never considered completing a living will or health care proxy, but 33% and 45% of participants had talked with loved ones about being kept alive on machines or about quality of life, respectively. Greater knowledge of ACP correlated weakly with a favorable view of ACP (P = .002). Young adults should be made aware of their ability to dictate the care they want to receive in situations in which they are incapacitated, as well as advocate for their family members to engage in ACP. Discovering characteristics associated with readiness to engage in ACP can enable hospice and palliative care nurses to tailor discussions with young adults regarding ACP.

Patients' perspectives on dialysis decision-making and end-of-life care .

Background: Few studies have explored dialysis patients’ perspectives on dialysis decision-making and end-of-life-care (EoLC) preferences. We surveyed a racially diverse cohort of maintenance dialysis patients in the Cleveland, OH, USA, metropolitan area. Materials and methods: In this cross-sectional study, we administered a 41-item questionnaire to 450 adult chronic dialysis patients. Items assessed patients’ knowledge of their kidney disease as well as their attitudes toward chronic kidney disease (CKD) treatment issues and EoLC issues. Results: The cohort included 67% Blacks, 27% Caucasians, 2.8% Hispanics, and 2.4% others. The response rate was 94% (423/450). Most patients considered it essential to obtain detailed information about their medical condition (80.6%) and prognosis (78.3%). Nearly 19% of respondents regretted their decision to start dialysis. 41% of patients would prefer treatment(s) aimed at relieving pain rather than prolonging life (30.5%), but a majority would want to be resuscitated (55.3%). Only 8.4% reported having a designated healthcare proxy, and 35.7% reported completing a living will. A significant percentage of patients wished to discuss their quality of life (71%), psychosocial and spiritual concerns (50.4%), and end-of-life issues (38%) with their nephrologist. Conclusion: Most dialysis patients wish to have more frequent discussions about their disease, prognosis, and EoLC planning. Findings from this study can inform the design of future interventions.

Technology Access, Technical Assistance, and Disparities in Inpatient Portal Use.

Disadvantaged populations, including minorities and the elderly, use patient portals less often than relatively more advantaged populations. Limited access to and experience with technology contribute to these disparities. Free access to devices, the Internet, and technical assistance may eliminate disparities in portal use. To examine predictors of frequent versus infrequent portal use among hospitalized patients who received free access to an iPad, the Internet, and technical assistance. This subgroup analysis includes 146 intervention-arm participants from a pragmatic randomized controlled trial of an inpatient portal. The participants received free access to an iPad and inpatient portal while hospitalized on medical and surgical cardiac units, together with hands-on help using them. We used logistic regression to identify characteristics predictive of frequent use. More technology experience (adjusted odds ratio [OR] = 5.39, p = 0.049), less severe illness (adjusted OR = 2.07, p = 0.077), and private insurance (adjusted OR = 2.25, p = 0.043) predicted frequent use, with a predictive performance (area under the curve) of 65.6%. No significant differences in age, gender, race, ethnicity, level of education, employment status, or patient activation existed between the frequent and infrequent users in bivariate analyses. Significantly more frequent users noticed medical errors during their hospital stay. Portal use was not associated with several sociodemographic characteristics previously found to limit use in the inpatient setting. However, limited technology experience and high illness severity were still barriers to frequent use. Future work should explore additional strategies, such as enrolling health care proxies and improving usability, to reduce potential disparities in portal use.

Vaccines Should Not Be a Sticking Point

Vaccines Should Not Be a Sticking Point

Feasibility of Educating Stem Cell Transplant Patients on Advance Care Planning: A Pilot Study

▪IntroductionPatients with hematologic malignancies undergoing hematopoietic cell transplants (HCT) experience a high symptom burden, suffer from diminished quality of life, and often receive aggressive care at the end of life. Low completion rates of advance directives (ADs) regarding preferences for end-of-life care in this population are also common. Our study aims to examine the feasibility of a timely educational intervention about an online AD (i.e., OurCareWishes.org; OCW) for patients with hematologic malignancies undergoing autologous or allogeneic stem cell transplantation. We also seek to ascertain whether this educational intervention impacts patients' decisional conflict regarding transplant and quality of life.MethodsPatients scheduled for HCT were recruited and randomized to receive either in-person guided education about OCW (i.e., intervention) or standard AD information (i.e., usual care) 3-4 weeks prior to hospital admission for transplantation. Patients receiving the educational intervention were offered the opportunity to specify their preferences for life-sustaining or comfort-oriented care using vignettes and ultimately complete two components of online AD (e.g., health care proxy and living will). All patients received in-person follow-ups during their transplant and 2 months post-transplant appointments, during which patients who had received the educational intervention were re-approached about completing the online AD. Patients indicating a previously completed AD were offered the opportunity to review. At all three time points, patients were surveyed on their (1) decisional conflict regarding transplant using Decision Conflict Scale (DCS, 16-item, Range 0-60) and their (2) overall quality of life using McGill Quality of Life (MQoL) scale (16-item, Range 1-7). Greater DCS and MQoL scores represent greater decision conflict and better quality of life, respectively. We conducted a one-way repeated measures ANOVA to examine the effect of the educational AD intervention on decisional outcomes and quality of life.ResultsA total of 96 patients (98% Recruitment Rate) consented to participate and were randomized to receive either OCW (n=47) or standard AD information (n=49). They underwent either autologous (n=29), allogeneic reduced intensity (n=29), or allogeneic myeloablative (n=38) HCT. Most patients were male (n=57; 61%) and White (n=85; 89%). The median age was 59 (IQR=49.5-65.5) years (Table 1). There were no differences between intervention and usual care groups in their rating for overall quality of life and decisional conflict at all three timepoints (all p>0.05). 48% of patients (n=49) self-reported to have completed an AD prior this study, but only 43% (n=21) had a current AD uploaded to the EHR. Moreover, less than 6% of patients who received the OCW intervention fully completed the online AD.ConclusionsThis pilot study demonstrated the feasibility of administering a brief educational intervention on advance care planning (ACP) in patients with hematologic malignancies preparing for HCT. Participants in this study were generally receptive to discussions about advance care planning, even when presented by non-clinical staff. Education about advance directives does not appear to negatively affect decisional outcomes or quality of life. Nonetheless, further research should focus on how to increase AD completion rates, possibly through multidisciplinary team engagement in serious illness conversations and coordinated physician/patient incentives. Future studies should examine the impact of education of AD on aggressiveness of care and end-of-life outcomes in patients undergoing HCT. DisclosuresNo relevant conflicts of interest to declare.

Inadequate Illness Understanding and Suboptimal Levels of Advance Care Planning in Patients with Aggressive Lymphoma

Introduction. The prognosis of an aggressive lymphoma can change significantly after disease progression following first line treatment, with the chance of cure changing from likely to unlikely. This sudden shift creates a unique context for illness understanding and advance care planning (ACP). Yet, research on illness understanding and ACP has focused primarily on patients with solid tumors rather than hematologic malignancies, a notable gap given the relationship between ACP and receipt of care consistent with patient preferences. In this study, we examined illness understanding, rates of ACP engagement, and reasons for lack of ACP engagement in patients with recurrent aggressive B-cell lymphomas.Methods. Patients (n=27, Table 1) with aggressive B-cell lymphomas that progressed after first or second line treatment were recruited from an urban academic medical center. Self-report measures of illness understanding (i.e., aggressiveness, terminality, curability) and ACP (i.e., discussions of care preferences, completion of advance directives) were administered over the telephone by trained study staff. Frequency and descriptive statistics were used to examine sample characteristics, illness understanding, and rates of ACP.Results. Over two-thirds of the sample described their illness as aggressive (n=18, 69.2%) but less than one-third reporting being terminally ill (n=8, 29.6%) and having incurable disease (n=6, 22.2%).The majority of the sample had a healthcare proxy (HCP; n=22, 81.5%; Table 2). Reasons for not designating a HCP included that patients were considering whom to choose (n=2, 7.4%), had not thought about it (n=2, 7.4%), and did not know the definition of a HCP (n=1, 3.7%). Two-thirds of the sample (n=17, 65.4%) had not completed a living will. Of those who completed a living will, 22.2% (n=2) selected comfort measures only, 22.2% (n=2) selected limited medical interventions, and 11.1% (n=1) selected no limitations on medical interventions. Almost half of patients who completed a living will (n=4, 44.4%) did not know their documented care preference and 14.5% (n=4) of the total sample did not know the definition of a living will.Over one-third of patients (n=10, 37%) had not decided about their DNR status and 11.1% (n=3) did not have a DNR order because they wanted resuscitation to be attempted. Reasons for not making a DNR decision included that patients did not know the definition of a DNR order (n=3, 11.1%), had not thought about it (n=3, 11.1%), were considering whether they wanted a DNR order (n=1, 3.7%), and other (n=3, 11.1%). Less than half of the sample (n=12, 44.4%) reported writing down or talking to someone about the care they would like to receive should they become critically ill. Of those patients who discussed their care preferences, only 11.1% (n=3) discussed their preferences with a healthcare provider.Conclusions. Our findings identify several issues that require potential intervention and validation. Many patients with recurrent aggressive lymphoma do not accurately understand their prognosis. Research identifying the causes of this gap (e.g., information is not provided, information is provided using language the patient cannot understanding, patients' emotions interfere with understanding) will inform the development of targeted interventions to improve patient understanding. Longitudinal research on illness understanding and strategies for improving illness understanding will be particularly important for patients with aggressive lymphoma due to the sudden change in prognosis as the disease progresses.Additionally, research on strategies to promote discussion of patients' EOL care wishes with their oncologist/care team is needed, particularly in light of evidence that these discussions facilitate receipt of care consistent with patients' preferences. Further, patients with aggressive lymphoma may benefit from basic information on and assistance in completion of a living will and DNR order. Given that most patients with recurrent aggressive lymphoma will die of their disease, our study highlights the need for greater prioritization of and support for patient education on the nature of aggressive lymphoma and completion of advanced directives. DisclosuresMartin:Seattle Genetics: Consultancy; Gilead: Consultancy; Janssen: Consultancy; AstraZeneca: Consultancy; Kite: Consultancy; Bayer: Consultancy. Leonard:Genentech/Roche: Consultancy; AstraZeneca: Consultancy; Novartis: Consultancy; Karyopharm: Consultancy; United Therapeutics: Consultancy; Celgene: Consultancy; Pfizer: Consultancy; Juno: Consultancy; ADC Therapeutics: Consultancy; Biotest: Consultancy; BMS: Consultancy; Sutro: Consultancy; Gilead: Consultancy; Bayer: Consultancy; MEI Pharma: Consultancy.

Is Annual Income a Predictor of Completion of Advance Directives (ADs) in Patients With Cancer.

Completion of advance directives (ADs) enhances the likelihood of receiving goal-concordant treatments near the end of life. Previous research on community samples have shown that completion of ADs is less common in lower socioeconomic status demographic group; there is a paucity of such research in patients with cancer. To study the effect of income and education on the completion of ADs. Patients with cancer having lower incomes and education levels would be less likely to report completing ADs. We conducted cross-sectional analyses of data provided by patients (n = 265) enrolled in the Values and Options in Cancer Care clinical trial. Patients with advanced cancer reported whether they had (1) completed a living will or (2) designated a health-care proxy. Response options for both questions were yes (scored 1), no (scored 0), and unsure (scored 0). We studied the association of lower household income (≤US$20 000) and education level (never attended college) with AD scores. Patients with lower annual incomes had lower AD scores (estimate -0.44; confidence intervals [CI]: -0.71 to -0.16, P = .001); the association between higher educational attainment (some college or more) and completion of ADs was not statistically significant (estimate 0.04, CI: -0.16 to 0.24, P = .70). Interventions to promote completion of ADs among lower income patients with serious illnesses are needed.