Advance care planning in patients with advanced cancer: A 6-country, cluster-randomised clinical trial.

BACKGROUND: Advance care planning (ACP) supports individuals to define, discuss, and record goals and preferences for future medical treatment and care. Despite being internationally recommended, randomised clinical trials of ACP in patients with advanced cancer are scarce. METHODS AND FINDINGS: To test the implementation of ACP in patients with advanced cancer, we conducted a cluster-randomised trial in 23 hospitals across Belgium, Denmark, Italy, Netherlands, Slovenia, and United Kingdom in 2015-2018. Patients with advanced lung (stage III/IV) or colorectal (stage IV) cancer, WHO performance status 0-3, and at least 3 months life expectancy were eligible. The ACTION Respecting Choices ACP intervention as offered to patients in the intervention arm included scripted ACP conversations between patients, family members, and certified facilitators; standardised leaflets; and standardised advance directives. Control patients received care as usual. Main outcome measures were quality of life (operationalised as European Organisation for Research and Treatment of Cancer [EORTC] emotional functioning) and symptoms. Secondary outcomes were coping, patient satisfaction, shared decision-making, patient involvement in decision-making, inclusion of advance directives (ADs) in hospital files, and use of hospital care. In all, 1,117 patients were included (442 intervention; 675 control), and 809 (72%) completed the 12-week questionnaire. Patients' age ranged from 18 to 91 years, with a mean of 66; 39% were female. The mean number of ACP conversations per patient was 1.3. Fidelity was 86%. Sixteen percent of patients found ACP conversations distressing. Mean change in patients' quality of life did not differ between intervention and control groups (T-score -1.8 versus -0.8, p = 0.59), nor did changes in symptoms, coping, patient satisfaction, and shared decision-making. Specialist palliative care (37% versus 27%, p = 0.002) and AD inclusion in hospital files (10% versus 3%, p < 0.001) were more likely in the intervention group. A key limitation of the study is that recruitment rates were lower in intervention than in control hospitals. CONCLUSIONS: Our results show that quality of life effects were not different between patients who had ACP conversations and those who received usual care. The increased use of specialist palliative care and AD inclusion in hospital files of intervention patients is meaningful and requires further study. Our findings suggest that alternative approaches to support patient-centred end-of-life care in this population are needed. TRIAL REGISTRATION: ISRCTN registry ISRCTN63110516.

Spiritual needs assessments and measurements.

PURPOSE OF REVIEW: This review discusses the developments in spiritual needs assessments and measurements in end-of-life care. The review considers spiritual needs assessments from the perspective of palliative care patients, their families and caregivers, and healthcare professionals. RECENT FINDINGS: Spiritual needs assessments vary significantly along the dimensions of content and domains. These needs assessments have the potential to deepen our insight and to identify those who are most at risk for spiritual distress, but few are practical and simple enough to use in everyday clinical practice, and for the research, few are cross-culturally validated. Spirituality is a complex construct, although 'relatedness' was recognized as a core dimension of spirituality in addition to existential beliefs and values related to meaning and purpose. Little is known about the spiritual needs in elderly patients, in the cognitively impaired, and during the dying process. The spiritual needs of family caregivers need more support and attention. SUMMARY: Spirituality is considered to be one of the patient's vital signs and should be routinely screened and assessed. Research in spiritual care should be ongoing for all palliative care patients as well as for those with specific needs such as mental, neurological, or cognitive impairment. There is also a knowledge gap concerning how spiritual needs change during the progression of the disease trajectory. More work must be done on the spiritual concerns of family caregivers.