title: Advance directives in patients with advanced cancer receiving active treatment: attitudes, prevalence, and barriers.
abstract: The purposes of the study were to assess awareness and prevalence of advance directives (ADs) among patients with advanced cancer undergoing active outpatient care and to determine factors associated with AD completion before and after the diagnosis of cancer.
  
  
  
  Patients with advanced solid tumor malignancy receiving treatment at the Chemotherapy Day Unit were approached for recruitment. They completed an onsite questionnaire about completion and timing of ADs, demographic information, and perceived health; a review of their medical records was conducted to document their cancer care and co-morbidities. Multinomial logistic regression analysis identified factors associated with the timing of AD completion (pre-cancer, post-cancer, or not at all).
  
  
  
  Two hundred patients were enrolled, with 193 surveys available for analysis. ADs were completed in 55 % (106/193) of patients, including a living will in 33 % (63/193), a power of attorney in 49 % (95/193), and a do-not-resuscitate (DNR) designation in 18 % (35/193). Most patients (53 %) had completed an AD before being diagnosed with cancer. Higher income (p = 0.02) and age (p = 0.004) were associated with AD completion pre-cancer diagnosis; discussion of end-of-life care (p = 0.02) and palliative care referral (p < 0.0001) were associated with AD completion post-cancer diagnosis.
  
  
  
  This study demonstrates that different factors may influence the completion of ADs before and after a diagnosis of cancer and highlights the potential for early palliative care to impact the completion of ADs in patients with advanced cancer who are undergoing active cancer treatment.
authors.affiliation: Department of Medicine, Division of Medical Oncology, University of Toronto, Toronto, ON, Canada.|Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, 16th floor, Toronto, ON, M5G 2M9, Canada.
authors.forename: Julie C
authors.initials: JC
authors.lastname: McDonald
authors.affiliation: Department of Medicine, Mississauga Hospital, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.
authors.forename: Jeanne M
authors.initials: JM
authors.lastname: du Manoir
authors.affiliation: Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, 16th floor, Toronto, ON, M5G 2M9, Canada.
authors.forename: Nanor
authors.initials: N
authors.lastname: Kevork
authors.affiliation: Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
authors.forename: Lisa W
authors.initials: LW
authors.lastname: Le
authors.affiliation: Department of Medicine, Division of Medical Oncology, University of Toronto, Toronto, ON, Canada. camilla.zimmermann@uhn.ca.|Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Ave, 16th floor, Toronto, ON, M5G 2M9, Canada. camilla.zimmermann@uhn.ca.|Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada. camilla.zimmermann@uhn.ca.
authors.forename: Camilla
authors.initials: C
authors.lastname: Zimmermann
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000639:trends*; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000628:therapy*; D015995:Prevalence; D011795:Surveys and Questionnaires; D013727:Terminal Care
keywords: Advance care planning; Advance directives; Advanced cancer; Attitudes; Health knowledge; Palliative care; Practice