title: Paradoxes in advance care planning: the complex relationship of oncology patients, their physicians, and advance medical directives.
abstract: OBJECTIVE
  Many seriously ill patients with cancer do not discuss prognosis or advance directives (ADs), which may lead to inappropriate and/or unwanted aggressive care at the end of life. Ten years ago, patients with cancer said they would not like to discuss ADs with their oncologist but would be willing to discuss them with an admitting physician. We assessed whether this point of view still held.
  
  
  METHODS
  Semi-structured interviews were conducted with 75 consecutively admitted patients with cancer in the cancer inpatient service.
  
  
  RESULTS
  Of those enrolled, 41% (31 of 75) had an AD. Nearly all (87%, 65 of 75) thought it acceptable to discuss ADs with the admitting physician with whom they had no prior relationship, and 95% (62 of 65) thought that discussing AD issues was very or somewhat important. Only 7% (5 of 75) had discussed ADs with their oncologist, and only 23% (16 of 70) would like to discuss ADs with their oncologist. When specifically asked which physician they would choose, 48% (36 of 75) of patients would prefer their oncologist, and 35% (26 of 75) would prefer their primary care physician.
  
  
  CONCLUSIONS
  Fewer than half of seriously ill patients with cancer admitted to an oncology service have an AD. Only 23% (16 of 70) would like to discuss their ADs with their oncologist but nearly all supported a policy of discussing ADs with their admitting physician. However, fully 48% (36 of 75) actually preferred to discuss advance directives with their oncologist if AD discussion was necessary. We must educate patients on why communicating their ADs is beneficial and train primary care physicians, house staff, hospitalists, and oncologists to initiate these difficult discussions.
authors.affiliation: School of Medicine and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298-0230, USA.
authors.forename: Lindsay A
authors.initials: LA
authors.lastname: Dow
authors.forename: Robin K
authors.initials: RK
authors.lastname: Matsuyama
authors.forename: V
authors.initials: V
authors.lastname: Ramakrishnan
authors.forename: Laura
authors.initials: L
authors.lastname: Kuhn
authors.forename: Elizabeth B
authors.initials: EB
authors.lastname: Lamont
authors.forename: Laurel
authors.initials: L
authors.lastname: Lyckholm
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Smith
mesh_terms: D000328:Adult; D032722:Advance Care Planning; D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008495:Medical Oncology; D008875:Middle Aged; D009369:Neoplasms / Q000523:psychology*; D010166:Palliative Care; D057240:Patient Preference; D010817:Physician-Patient Relations; D010821:Physicians, Family; D013727:Terminal Care; D055815:Young Adult