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Outcomes After Hematopoietic Stem-Cell Transplantation for Hematologic Malignancies in Patients With or Without Advance Care Planning

Apar Kishor Ganti, Stephanie J. Lee, Julie M. Vose, Marcel P. Devetten, R. Gregory Bociek, James O. Armitage, Philip J. Bierman, Lori J. Maness, Elizabeth C. Reed, Fausto R. Loberiza, Jr

From the Section of Oncology-Hematology, Department of Internal Medicine, University of Nebraska Medical Center; the Department of Internal Medicine, Omaha Veterans Affairs Medical Center, Omaha, NE; and the Fred Hutchinson Cancer Research Center, Seattle, WA

Address reprint requests to Apar Kishor Ganti, MD, University of Nebraska Medical Center, Section of Oncology-Hematology, 987680 Nebraska Medical Center, Omaha, NE 68198-7680; e-mail: aganti{at}unmc.edu

Purpose Engagement in advance care planning (ACP) is viewed as a way to prepare for possible death. In patients undergoing hematopoietic stem-cell transplantation (HSCT), an aggressive but possibly curative procedure for cancer, encouraging engagement in ACP is difficult. We conducted this analysis to determine if engagement in ACP among patients who undergo HSCT is associated with adverse outcomes.

Patients and Methods Adult patients who were undergoing their first HSCT for hematologic malignancies between 2001 and 2003 were included. ACP was defined as having a living will, a power of attorney for health care, or life-support instructions. Outcomes assessed included the length of hospital stay, in-hospital mortality, and overall survival.

Results Of the 343 patients, 172 did not have ACP, whereas 171 did have ACP, and 127 of those were reviewable. Of those with reviewable ACP, 28 patients (22%) completed ACP before cancer diagnosis, 87 (68%) completed ACP after the cancer diagnosis but before HSCT, and 12 (10%) engaged in ACP after HSCT. Patients without ACP before HSCT had a significantly greater risk of death compared with patients with ACP (hazard ratio, 2.11; 95% CI, 1.34 to 3.33; P = .001) while adjusting for statistically significant factors.

Conclusion Our study demonstrated that lack of engagement in ACP is associated with adverse outcomes after HSCT. Thus, the patients least likely to have planned for poor outcomes are the ones most likely to face them. Additional studies should evaluate the nature of this association and should seek modifiable explanatory factors that could be the target of interventions.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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