title: Association of Early Patient-Physician Care Planning Discussions and End-of-Life Care Intensity in Advanced Cancer.
abstract: BACKGROUND
  Early patient-physician care planning discussions may influence the intensity of end-of-life (EOL) care received by veterans with advanced cancer.
  
  
  OBJECTIVE
  The study objective was to evaluate the association between medical record documentation of patient-physician care planning discussions and intensity of EOL care among veterans with advanced cancer.
  
  
  METHODS
  This was a retrospective cohort study. Subjects were 665 veteran decedents diagnosed with stage IV colorectal, lung, or pancreatic cancer in 2008, and followed till death or the end of the study period in 2011. We estimated the effect of patient-physician care planning discussions documented within one month of metastatic diagnosis on the intensity of EOL care measured by receipt of acute care, intensive interventions, chemotherapy, and hospice care, using multivariate logistic regression models.
  
  
  RESULTS
  Veterans in our study were predominantly male (97.1%), white (74.7%), with an average age at diagnosis of 66.4 years. Approximately 31% received some acute care, 9.3% received some intensive intervention, and 6.5% had a new chemotherapy regimen initiated in the last month of life. Approximately 41% of decedents received no hospice or were admitted within three days of death. Almost half (46.8%) had documentation of a care planning discussion within the first month after diagnosis and those who did were significantly less likely to receive acute care at EOL (OR: 0.67; p=0.025). Documented discussions were not significantly associated with intensive interventions, chemotherapy, or hospice care.
  
  
  CONCLUSIONS
  Early care planning discussions are associated with lower rates of acute care use at the EOL in a system with already low rates of intensive EOL care.
authors.affiliation: 1 RAND Corporation , Santa Monica, California.
authors.forename: Sangeeta C
authors.initials: SC
authors.lastname: Ahluwalia
authors.affiliation: 9 Department of Health Science, California State University , Fullerton, Fullerton, California.
authors.forename: Diana M
authors.initials: DM
authors.lastname: Tisnado
authors.affiliation: 2 VA Greater Los Angeles Medical Center , Los Angeles, California.|3 UCLA School of Medicine , Los Angeles, California.
authors.forename: Anne M
authors.initials: AM
authors.lastname: Walling
authors.affiliation: 4 Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University , Baltimore, Maryland.
authors.forename: Sydney M
authors.initials: SM
authors.lastname: Dy
authors.affiliation: 5 VA Palo Alto Healthcare System , Palo Alto, California.|6 Stanford University School of Medicine , Palo Alto, California.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.affiliation: 7 UCLA Fielding School of Public Health , Los Angeles, California.
authors.forename: Susan L
authors.initials: SL
authors.lastname: Ettner
authors.affiliation: 8 University of California , San Francisco, California.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Kim
authors.affiliation: 2 VA Greater Los Angeles Medical Center , Los Angeles, California.
authors.forename: Philip
authors.initials: P
authors.lastname: Pantoja
authors.affiliation: 2 VA Greater Los Angeles Medical Center , Los Angeles, California.
authors.forename: Hannah C
authors.initials: HC
authors.lastname: Schreibeis-Baum
authors.affiliation: 2 VA Greater Los Angeles Medical Center , Los Angeles, California.|3 UCLA School of Medicine , Los Angeles, California.
authors.forename: Karl A
authors.initials: KA
authors.lastname: Lorenz
mesh_terms: D032722:Advance Care Planning / Q000458:organization & administration* / Q000592:standards; D000368:Aged; D015331:Cohort Studies; D003142:Communication; D003657:Decision Making; D004282:Documentation; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D015999:Multivariate Analysis; D009362:Neoplasm Metastasis; D009369:Neoplasms / Q000473:pathology / Q000523:psychology*; D010817:Physician-Patient Relations; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods / Q000523:psychology* / Q000592:standards; D019452:Terminally Ill / Q000523:psychology*; D013997:Time Factors; D014481:United States; D058014:Veterans Health / Q000592:standards* / Q000639:trends