Facilitated Versus Patient-Directed Advance Care Planning Among Patients With Advanced Cancer: A Randomized Clinical Trial

PURPOSE 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. METHODS 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. RESULTS 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] v 4.08 [0.82]; adjusted mean difference, 0.25 [95% CI, 0.1 to 0.4]; P = .0014) and higher odds of completing an advance directive (74.8% v 60.6%; OR, 2.52 [95% CI, 1.27 to 5.0]; P = .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% v 88%; OR, 1.13 [95% CI, 0.5 to 2.6]; P = .76) or physicians (49.6% v 40.6%; OR, 1.53 [95% CI, 0.9 to 2.7]; P = .13), and all ACP behaviors increased significantly from baseline in both groups. CONCLUSION 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.