In recent decades, there have been efforts to bring appropriate and coordinated care of terminally ill patients out of the shadows of clinical medicine. Clinicians and patients alike within the cancer community have increasingly embraced the need for advance care planning (ACP). The results reported by Narang et al1 in this issue of JAMA Oncology document a disparity in the engagement of different components of the ACP process. While it is encouraging to see increasing implementation of durable power of attorney by patients with cancer, this is not matched by a similar level of use of living wills or end-of-life discussions. A communication gap apparently exists between patients and clinicians if the difficult conversations regarding preferred care toward the end of life are not taking place as they should. The findings of Narang et al,1 despite the inherent limitations in proxy-reported research methodology, suggest that an unintended scenario may be evolving in which the increasing use of power of attorney may be associated with patients relinquishing their opportunity to communicate end-of-life and living will care preferences. Hence, patients are de facto forcing surrogates who are granted power of attorney to make decisions in a communication vacuum. While creative solutions must be identified via continued research, some solutions may include routine updating of POLST (physician orders for life-sustaining treatment) for each admission, earlier engagement of palliative care teams, and further instruction of communication approaches to ACP discussion in the core postgraduate medical education curriculum.
Conflict of Interest Disclosures: None reported.
Thomas CR. Participatory Gaps in the Advance Care Planning Process of Patients With Cancer. JAMA Oncol. 2015;1(5):610. doi:10.1001/jamaoncol.2015.2088