Prospective Randomized Study of Advance Directives in Allogeneic Hematopoietic Cell Transplant Recipients. Transplantation and cellular therapy Tan, I. T., Sundaram, V., Ramirez, Y., Burnash, S., Kate Tierney, D., Muffly, L. S. 2021


BACKGROUND: Patients undergoing allogeneic HCT are at risk for high morbidity and mortality. Advance directives (AD) allow patients to express wishes regarding their care at the end of life, but these are not completed in the majority of patients undergoing HCT, with only 44% of deceased allogeneic HCT recipients at this institution completing an AD in the past decade. Increasing AD completion rate can improve quality of care for allogeneic HCT recipients.OBJECTIVE: Evaluating whether an alternative AD instrument can increase AD completion rate and patient satisfaction.STUDY DESIGN: We conducted a prospective, randomized controlled study of the traditional California AD vs. the use of a novel Letter AD, the Stanford What Matters Most Letter, in adult allogeneic HCT recipients. Patients 18 years and older undergoing first allogeneic HCT at Stanford University were eligible. Prior to HCT conditioning, enrolled patients were randomly assigned to complete either the traditional AD or the Letter AD. The primary endpoint was AD completion; the chi-squared test was used to compare the AD completion rate between arms. Wilcoxon rank-sum tests were used to compare uncertainty, satisfaction with decision-making, and satisfaction with the AD.RESULTS: Of the total 212 patients who were eligible, 126 (59.4%) were enrolled and randomized. The mean age was 53.7 years; 57(45.2%) were female; 74 (58.7%) were non-Hispanic White. The overall AD completion rate was 71.4% and did not differ between the traditional and Letter AD arms (70.3% vs 72.6%, P= 0.78). Of those who completed the Letter AD, 66.7%, 42.2%, and 46.7% of patients wished to die gently/naturally, at home, and/or with hospice, respectively. The traditional AD found that 62.2% wished to not prolong life if recovery was unlikely. Opinion surveys did not find differences in levels of satisfaction between the traditional and Letter AD.CONCLUSION: Completion rates of AD on this study were high (71.4%) in comparison to historically reported completion rates and did not significantly differ based upon AD version.

View details for DOI 10.1016/j.jtct.2021.03.030

View details for PubMedID 33836311