Schenker Yael, Belin Shane C, Wang Tianxiu, Sudore Rebecca L, Hammes Bernard, Arnold Robert M, Flowers Roberta, Chiu Eric, Hall Julian, Dudley-Morrissey Yvette, Ferrell Betty, Crowley-Matoka Megan, Brufsky Adam, Chu Edward, Gorantla Vikram, Mehta Dhaval, Thomas Roby, Yee Melissa, White Douglas
Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA.
Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA.
JCO Oncol Pract. 2025 Mar 19:OP2500046. doi: 10.1200/OP-25-00046.
Guidelines recommend advance care planning (ACP) to improve patient-centered care near the end of life (EOL), but the optimal approach is unknown. This single-blind, patient-level, randomized comparative effectiveness trial compared two patient-facing ACP interventions that are widely used but differ in costs and complexity.
Adult patients with advanced solid tumors and their caregivers were recruited from academic and community oncology clinics. Participants were randomly assigned to facilitated ACP using trained nurse facilitators versus patient-directed ACP using written and web-based tools. The primary outcome was patient-reported ACP engagement (assessed at baseline and 12 weeks using a 15-item validated survey; range, 0-5; higher scores indicate higher engagement). Secondary outcomes included advance directive completion and communication about EOL wishes.
A total of 400 patients enrolled (mean [SD] age, 67.9 [10.5] years; 192 women [48%]). At 12 weeks, patients in the facilitated versus patient-directed group reported higher ACP engagement (4.34 [0.78] 4.08 [0.82]; adjusted mean difference, 0.25 [95% CI, 0.1 to 0.4]; = .0014) and higher odds of completing an advance directive (74.8% 60.6%; OR, 2.52 [95% CI, 1.27 to 5.0]; = .008). There were no significant differences between the facilitated and patient-directed groups in the odds of having a conversation about EOL wishes with family or friends (88.9% 88%; OR, 1.13 [95% CI, 0.5 to 2.6]; = .76) or physicians (49.6% 40.6%; OR, 1.53 [95% CI, 0.9 to 2.7]; = .13), and all ACP behaviors increased significantly from baseline in both groups.
Facilitated ACP resulted in greater increases in ACP engagement and advance directive completion than patient-directed written and web-based materials. Although some patients with advanced cancer may engage in self-directed ACP, some may need additional facilitator support.
指南推荐进行预先护理计划（ACP）以改善临终（EOL）时以患者为中心的护理，但最佳方法尚不清楚。这项单盲、患者层面的随机对照有效性试验比较了两种广泛使用但成本和复杂性不同的面向患者的ACP干预措施。
从学术和社区肿瘤诊所招募患有晚期实体瘤的成年患者及其护理人员。参与者被随机分配接受由经过培训的护士促进的ACP，或使用书面和基于网络的工具进行患者自主的ACP。主要结局是患者报告的ACP参与度（在基线和12周时使用一份经过验证的15项调查问卷进行评估；范围为0至5；分数越高表明参与度越高）。次要结局包括预先指示的完成情况以及关于临终愿望的沟通。
共招募了400名患者（平均[标准差]年龄为67.9[10.5]岁；192名女性[48%]）。在12周时，接受促进式ACP的患者与接受患者自主式ACP的患者相比，报告的ACP参与度更高（4.34[0.78]对4.08[0.82]；调整后的平均差异为0.25[95%置信区间，0.1至0.4]；P = 0.0014），完成预先指示的几率也更高（74.8%对60.6%；比值比，2.52[95%置信区间，1.27至5.0]；P = 0.008）。在与家人或朋友谈论临终愿望的几率方面（88.9%对88%；比值比，1.13[95%置信区间，从0.5至2.6]；P = 0.76），以及与医生谈论临终愿望的几率方面（49.6%对40.6%；比值比，1.53[95%置信区间，0.9至2.7]；P = 0.13），促进式ACP组和患者自主式ACP组之间没有显著差异，并且两组的所有ACP行为从基线开始均显著增加。
与患者自主的书面和基于网络的材料相比，促进式ACP在ACP参与度和预先指示完成方面带来了更大的提升。虽然一些晚期癌症患者可能会进行自主的ACP，但一些患者可能需要额外的促进者支持。
