How to explain advance directives to an older adult patient with metastatic pancreatic adenocarcinoma and a history of smoking?

How to Explain Advance Directives to This Patient

You should discuss advance directives with this patient at the first visit as part of a comprehensive goals-of-care conversation, framing it as a tool to ensure their wishes guide all future medical decisions, particularly regarding life-sustaining treatments if they become too ill to communicate. 1

Why This Discussion Is Essential Now

The American Society of Clinical Oncology strongly recommends that goals of care, including advance directive discussions, occur with every patient with metastatic pancreatic cancer and their caregivers at the initial visit. 1 This is not optional—it is a core component of quality cancer care for this disease, which has a median life expectancy of less than 1 year and a 5-year survival of only 2%. 1

Framework for the Conversation

Start with Context, Not Forms

• Begin by explaining that metastatic pancreatic cancer is a serious illness where treatment focuses on controlling symptoms and extending quality life, but cure is not possible. 1
• Frame the advance directive as a way to maintain their control and autonomy throughout their illness, ensuring medical care aligns with what matters most to them. 1
• Emphasize this is about their values and preferences, not about "giving up" or stopping treatment. 1

Key Elements to Cover

Decision-Making Authority:

• Ask who they would want to make medical decisions if they cannot speak for themselves (healthcare proxy/durable power of attorney for healthcare). 1
• Explain this person should know their values deeply and be willing to advocate for their wishes even under pressure. 1

Treatment Preferences in Specific Scenarios:

• If their heart stops, do they want CPR attempted? (Explain realistic outcomes—CPR in metastatic cancer patients rarely results in meaningful recovery). 1
• If they cannot breathe on their own, do they want a breathing machine (mechanical ventilation)? 1
• If they cannot eat or drink, do they want artificial nutrition through tubes? 1
• What defines an unacceptable quality of life for them? (e.g., permanent unconsciousness, complete dependence, uncontrolled pain). 1

Goals and Values:

• What are their most important goals? (More time regardless of condition? Time at home? Comfort prioritized over life extension?) 1
• What gives their life meaning and quality? 1
• What are they most afraid of? 1

Practical Approach for This Specific Patient

Address the Smoking History Sensitively

• Smoking cessation should still be offered throughout the entire oncology care continuum, including end-of-life care, with emphasis on patient preferences and values. 1
• However, do not let smoking discussions derail or delay the advance directive conversation. 1
• If the patient expresses guilt about smoking contributing to their cancer, acknowledge their feelings but redirect to focus on what they can control now—their treatment choices and care preferences. 1

Integrate with Palliative Care

• A formal palliative care consult should be offered at this first visit, as patients with metastatic pancreatic cancer have high symptom burden and benefit from early palliative care involvement. 1
• Palliative care teams are expert at facilitating advance directive discussions and can provide ongoing support for these conversations. 1
• Clarify that palliative care is not hospice—it runs alongside cancer treatment to optimize quality of life. 1

Common Pitfalls to Avoid

• Don't delay this conversation thinking it's "too early" or will upset the patient—guidelines explicitly state this should happen at the first visit. 1
• Don't present advance directives as a one-time form to sign—frame it as an ongoing conversation that can be revisited as their illness evolves. 1
• Don't use medical jargon—use plain language like "breathing machine" instead of "intubation" and "heart restart" instead of "cardiopulmonary resuscitation." 1
• Don't make assumptions based on age—older adults have diverse preferences, and chronological age should not determine treatment intensity. 2, 3
• Don't separate advance directive discussions from treatment planning—they should inform each other, as treatment decisions reflect the patient's goals. 1

Documentation Requirements

• Document the advance directive discussion, the patient's stated preferences, and who their designated decision-maker is in the medical record at this first visit. 1
• Update this documentation at regular intervals as the patient's condition and preferences may evolve. 1
• Ensure the healthcare proxy/decision-maker has copies of all advance directive documents. 1

Reassessment Strategy

• Revisit goals of care and advance directive preferences at key transition points: when starting new treatment lines, when disease progresses, when performance status declines, or when the patient raises concerns about their condition. 1
• If the patient becomes too ill for further cancer-directed therapy (ECOG performance status ≥3), a hospice discussion and possible referral should occur. 1