Advance Care Planning and End-of-Life Care in Elderly: A Twenty-Four Month Cohort of Three Hundred and Fifty-Eight Patients with Serious Advanced Illness Advance Care Planning Cascade, Goals-of-Care Concordance, and Determinants Across Four Frailty Strata

Abstract

End-of-life care in elderly patients with serious advanced illness sits at the intersection of patient autonomy, family involvement, clinical judgment, and resource allocation. Advance care planning (ACP) the structured process of patients discussing values, preferences, and treatment goals with clinicians and family has emerged as central to delivering care concordant with patient values. We undertook a 24-month prospective cohort study of 358 elderly patients with serious advanced illness (advanced organ failure, advanced dementia, advanced cancer, or end-stage frailty) enrolled in an integrated palliative and geriatric care programme. ACP engagement cascaded through enrolment (86.0%), initial conversation (73.7%), goals of care documentation (60.9%), treatment preferences (49.7%), and accessible documents at end-of-life (41.3%). Among 358 patients, 175 died during follow-up. Place of death distribution differed substantially by ACP completion: comprehensive ACP achieved 14% home and 17% hospice/palliative deaths combined with only 17% ICU deaths, no-ACP patients had 48% ICU deaths and only 4% home. Preference-concordant care was achieved in 86.5% of patients with accessible ACP documents. Strongest predictors of preference-concordant care included comprehensive ACP completion, designated surrogate, family involvement, palliative team involvement, and document accessibility.

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