Advance care planning documentation prior to end-of-life systemic therapy: A single institution retrospective review.

Abstract

e24031 Background: Systemic anticancer therapy (SACT) at end-of-life (EOL) is associated with decreased quality of life and high healthcare use. Despite multiple guidelines focused on reducing EOL SACT, rates have not declined nationally. While prior studies have shown EOL discussions are associated with decreased EOL SACT use, literature is lacking on the frequency and quality of such discussions prior to EOL SACT. Methods: We conducted a retrospective study of care patterns and advance care planning (ACP) documentation by medical oncologists within the last 6 months of life and prior to the final dose of treatment among patients with solid tumors who received EOL SACT at MD Anderson. Results: From 4/2024 to 10/2024, 275 patients received SACT within 30 days of death. The mean death age was 62 years (SD 13.8). The majority had metastatic disease (88%) and three or more ED visits and/or admissions in the prior 3 months (52.7%). Half of the patients died in the inpatient setting, including 12% in the ICU, while 8% died at home, 29% on hospice, and 13% with unknown death locations. Final SACT type was chemotherapy (39.3%), immunotherapy (16%), targeted therapy (21.1%), chemotherapy and immunotherapy (9.8%), chemotherapy and targeted therapy (7.3%), immunotherapy and targeted therapy (6.2%), and cellular therapy (0.36%). The final dose of SACT was given in 30.6% of patients as the first line of therapy, 24% as second line, and 45.5% as third or later line. 39.6% of patients died during the first cycle of their final SACT and 23.64% of SACT were given in the inpatient setting. In the last six months of life and prior to the final dose of treatment, 119 (43.3%) patients had at least one ACP note. Among those with ACP notes, 54.2% had documented discussions of expected survival, most frequently estimated as either months (45.3%) or years (32.8%). The majority (82.4%) had recorded discussions of the intent of final treatment, which was most frequently for life prolongation (93.9%). 61.3% of patients had recorded discussions on code status with 18.5% opting for do-not-resuscitate. Documentation of hospice discussions were infrequent (13.4%). Conclusions: 56.7% patients who received EOL SACT did not have ACP notes in the last six months of life and prior to the final dose of SACT. Among patients with ACP notes, the majority had documented discussions on prognosis, intent of final treatment, and code status. However, prognosis was often overestimated and hospice discussions were infrequent. Future work will focus on identifying those at high risk of mortality and improving the quality and frequency of EOL ACP discussions. ACP documentation characteristics among patients with ACP notes. ACP documentation characteristics N % Discussed Life Expectancy 64 54.2 Weeks 2 3.1 Months 29 45.3 Years 21 32.8 Discussed intent of final treatment 98 82.4 Life prolongation 92 93.9 Cure 6 6.1 Discussed hospice 16 13.4 Discussed code status 73 61.3