Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2025 May 1;8(5):e259150.
doi: 10.1001/jamanetworkopen.2025.9150.

An Intervention to Increase Advance Care Planning Among Older Adults With Advanced Cancer: A Randomized Clinical Trial

Angelo E Volandes  1   2   3   4 , Yuchiao Chang  3 , Joshua R Lakin  5   6   7 , Michael K Paasche-Orlow  8 , Charlotta Lindvall  5   6   7 , Seth N Zupanc  5   9 , Diana Martins-Welch  10   11 , Maria T Carney  10   11 , Edith A Burns  10   11 , Jennifer Itty  10 , Kaitlin Emmert-Tangredi  10 , Narda J Martin  10 , Shreya Sanghani  10 , Jon Tilburt  12 , Kathryn I Pollak  13 , Aretha Delight Davis  4 , Cynthia Garde  4 , Michael J Barry  3   7 , Areej El-Jawahri  3   7 , Lisa Quintiliani  8 , Kate Sciacca  5   6 , Julie Goldman  5 , James A Tulsky  5   6   7
Affiliations
Randomized Controlled Trial

An Intervention to Increase Advance Care Planning Among Older Adults With Advanced Cancer: A Randomized Clinical Trial

Angelo E Volandes et al. JAMA Netw Open. .

Abstract

Importance: Many older adults with advanced cancer never communicate goals of care or treatment preferences to their clinicians, raising the risk that care received will not match their values. Scalable models of care may help surmount this barrier.

Objective: To test whether a combined patient and clinician intervention increased the rate of advance care planning (ACP) documentation in large health care systems.

Design, setting, and participants: This stepped-wedge cluster randomized clinical trial using an open cohort design included patients aged 65 years or older with advanced cancer seen at oncology clinics in 3 health care systems located in the US South, Midwest, and Mid-Atlantic regions from April 1, 2020, to November 30, 2022. Data collection ended in 2024.

Intervention: The intervention involved delivering brief evidence-based patient-facing video decision aids available in 25 languages as well as goals-of-care communication training to oncology clinicians. Patients in the control period received usual care.

Main outcomes and measures: The primary outcome was ACP documentation, which included any electronic health record documentation of a goals-of-care conversation, palliative care, hospice, or limitation of life-sustaining treatments, identified via a validated natural language processing program. Analysis was performed on an intention-to-treat basis.

Results: Twenty-nine practices, comprising 13 800 unique eligible patients with a total of 29 357 repeated measurements, were included (mean [SD] age, 74.5 [6.6] years; 52.3% men [15 344 of 29 357 measurements]). The proportion of patients with ACP documentation was greater in the intervention phase compared with the usual care phase (adjusted rate difference, 6.8% [95% CI, 2.8%-10.8%]; P < .001). ACP documentation in the intervention phase occurred among 3980 of 15 754 patients (25.3%) (goals-of-care conversation, 21.4% [3377 of 15 754]; palliative care, 9.6% [1517 of 15 754]; hospice, 5.4% [847 of 15 754]; and limitation of life-sustaining treatments, 7.2% [1128 of 15 754]). In comparison, ACP documentation in the usual care phase occurred among 2834 of 13 603 patients (20.8%) (goals-of-care conversation, 16.8% [2281 of 13 603]; palliative care, 9.5% [1287 of 13 603]; hospice, 5.3% [724 of 13 603]; and limitation of life-sustaining treatments, 8.4% [1149 of 13 603]).

Conclusions and relevance: In this stepped-wedge cluster randomized clinical trial for older adults with advanced cancer, a bundled evidence-based decision aid and communication training intervention increased the proportion of older patients with ACP documentation. This approach offers an innovative paradigm with a clinically meaningful increase in ACP documentation, a widely used quality metric that reflects high-quality patient-centered care delivery.

Trial registration: ClinicalTrials.gov Identifier: NCT03609177.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Volandes reported being president of ACP Decisions, a nonprofit organization that supports shared decision-making through video decision aids, outside the submitted work. Dr Lakin reported receiving grants from Dana-Farber Cancer Institute and the National Institutes of Health (NIH) paid to primary institution during the conduct of the study. Dr Davis reported being a co-founder, CEO and board member of ACP Decisions, a nonprofit organization that supports shared decision-making through video decision aids. Dr Barry reported receiving grants from Healthwise outside the submitted work. Dr El-Jawahri reported receiving personal fees from Incyte Corp, Tuesday Health, and Novartis outside the submitted work. Dr Tulsky reported being a founding director of VitalTalk, a nonprofit focused on serious illness communication skills training. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Participant Flow Diagram
Figure 2.
Figure 2.. Advance Care Planning (ACP) Documentation by 6-Month Step for the Intervention and Usual Care Periods
See this image and copyright information in PMC

References

    1. Sudore RL, Lum HD, You JJ, et al. . Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. J Pain Symptom Manage. 2017;53(5):821-832. - PMC - PubMed
    1. Curtis JR, Downey L, Back AL, et al. . Effect of a patient and clinician communication-priming intervention on patient-reported goals-of-care discussions between patients with serious illness and clinicians: a randomized clinical trial. JAMA Intern Med. 2018;178(7):930-940. - PMC - PubMed
    1. Hickman SE, Lum HD, Walling AM, Savoy A, Sudore RL. The care planning umbrella: the evolution of advance care planning. J Am Geriatr Soc. 2023;71(7):2350-2356. - PMC - PubMed
    1. Platts-Mills TF, Richmond NL, LeFebvre EM, et al. . Availability of advance care planning documentation for older emergency department patients: a cross-sectional study. J Palliat Med. 2017;20(1):74-78. - PMC - PubMed
    1. Grudzen CR, Buonocore P, Steinberg J, Ortiz JM, Richardson LD; AAHPM Research Committee Writing Group . Concordance of advance care plans with inpatient directives in the electronic medical record for older patients admitted from the emergency department. J Pain Symptom Manage. 2016;51(4):647-651. - PubMed

Publication types

Associated data