Patients with terminal brain cancer who watched a brief video illustrating options for end-of-life care were significantly more likely to indicate a preference for comfort measures only than were patients who listened to a verbal description of treatment choices. Practically all those viewing the video would choose not to receive cardiopulmonary resuscitation (CPR) after their cancer became advanced, compared with only half of those in the control group, report the authors of a study that will be published in the Journal of Clinical Oncology and has received early online release.
"Advanced care planning is challenging for both patients and physicians, probably because of difficulties with physician/patient communication and patients' limited knowledge about what the various levels of care really involve," says Angelo Volandes, MD, MPH, of the Massachusetts General Hospital (MGH) Department of Medicine, corresponding author of the Journal of Clinical Oncology article. "We previously studied whether video could help healthy elderly patients plan end-of-life care if they developed dementia, and as far as we know this is the first investigation of video as part of advanced care planning for cancer patients."
The research team enrolled 50 patients treated at the MGH Cancer Center for malignant glioma, the most common and deadly form of brain tumor. Upon entering the study, participants were asked a series of questions assessing their knowledge about advanced treatment measures - including the likely results of CPR or ventilator care - and whether they would choose to receive CPR after their cancer had reached an advanced stage.
Participants were then randomly assigned to either listen to a verbal description of three levels of care - life-prolonging care, including CPR and mechanical ventilation; basic hospital care, including the use of antibiotics and intravenous fluids; or comfort care only - or to view a 6-minute video illustrating those levels of care after listening to the same verbal narrative. The video depicted life-prolonging care with scenes of a simulated CPR administration and a ventilated patient in an intensive care unit; basic care was illustrated with hospitalized patients receiving treatments such as intravenous antibiotics; and comfort care showed patients receiving food, oxygen therapy and other comfort measures at home or in a hospice.
After either intervention, participants were again asked which level of care they would prefer when their cancer became advanced and whether they would choose to receive CPR. They were asked the knowledge assessment questions again and also took a standard assessment of how certain they were of their decisions. Those who viewed the video were asked about their reactions to what they had seen.
Among the 23 participants who viewed the video, 21 indicated a preference for receiving comfort care only. One chose basic care, one was undecided, but none chose life-prolonging care. About half of the narrative-only group - 14 of 27 participants - chose basic care, with six choosing comfort care and seven choosing life-prolonging care. Preferences regarding CPR had been almost the same before the intervention - with half indicating no, a third indicating yes and the rest uncertain - but when reinterviewed, all but two of those viewing the video said they would not choose CPR, while preferences among the control group were largely unchanged.
"In addition to being much more likely to prefer comfort-oriented care, those who viewed the video were overwhelmingly comfortable watching it and found it to be helpful and something they would recommend to other patients. They were also more certain of their decision and more knowledgeable about their options than control group members," says Volandes, an instructor in Medicine at Harvard Medical School.
"These results show how videos can help surmount communication barriers and reinforce patient/doctor discussions to solidify patients' choices for their medical care," he adds. "We are continuing to explore the role of video in advanced care planning for a more diverse group of patients with different forms of cancer." More information on this project is available at http://www.ACPdecisions.org.
The first author of the Journal of Clinical Oncology report is Areej El-Jawahri, MD, MGH Department of Medicine. Additional co-authors are April Eichler, MD, Scott Plotkin, MD, and Jennifer Temel, MD, MGH Cancer Center; Yuchiao Chang, PhD, and Michael Barry, MD, MGH Medicine; Lisa Podgurski, MD, University of Pittsburgh Medical Center; and Susan Mitchell, MD, Hebrew Senior Life, Boston. The study was supported by grants from the Foundation for Informed Medical Decision Making and the National Institutes of Health.
Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $600 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, systems biology, transplantation biology and photomedicine.