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. 2023 Jan 11;18(1):e0280197. doi: 10.1371/journal.pone.0280197

Advance care planning (ACP) to promote receipt of value-concordant care: Results vary according to patient priorities

Holly G Prigerson 1,*, Martin Viola 1, Paul K Maciejewski 1, Francesca Falzarano 1
Editor: Cari Malcolm2
PMCID: PMC9833543  PMID: 36630471

Abstract

Background

Benefits of advance care planning (ACP) have recently been questioned by experts, but ACP is comprised of discrete activities. Little is known about which, if any, ACP activities are associated with patients’ greater likelihood of receiving value-concordant end-of-life (EoL) care.

Objectives

To determine which ACP activities [Do-Not-Resuscitate (DNR) order completion, designation of a healthcare proxy (HCP), and/or EoL discussions with physicians], individually and in combination, are associated with the greatest likelihood of receiving value-concordant care, and how results may vary based on patient-reported EoL care priorities.

Methods

Data from 2 federally-funded, multisite, prospective cohort studies of EoL cancer care from 2002–2019 were analyzed. Cancer patients (N = 278) with metastatic disease refractory to chemotherapy were interviewed for a baseline assessment and followed prospectively until death. Interviews regarding patient priorities occurred a median of 111 days prior to death; data regarding EoL medical care were collected post-mortem from caregiver interviews and medical record abstraction. Patients who 1) prioritized life-extending care, and then received life-extending care (or avoided hospice care), or 2) prioritized comfort-focused care, and then avoided life-extending care (or received hospice care) in the last week of life, were coded as receiving value-concordant care.

Results

After inverse propensity score weighting, the ACP combination associated with the largest proportion of patients receiving value-concordant care was DNR, HCP, and EoL discussions (87% vs. 64% for no ACP activities; OR = 3.91, p = 0.006). In weighted analyses examining each ACP activity individually, DNR orders were associated with decreased likelihood of life-extending care (89% vs. 75%; p = 0.005) and EoL discussions were associated with increased likelihood of hospice care (77% vs. 55%; p = 0.002) among patients prioritizing comfort. ACP activities were not significantly associated with increased likelihood of receiving value-concordant care among patients prioritizing life-extension.

Conclusions and relevance

For patients who prioritize comfort, EoL discussions with physicians and completion of DNR orders may improve odds of receiving value-concordant EoL care. For patients who prioritize life-extension, ACP does not appear to improve odds of receiving value-concordant EoL care.

Introduction

Advance care planning (ACP), including the completion of Do-Not-Resuscitate (DNR) orders and designation of a healthcare proxy (HCP), was devised to promote value-concordant care for dying patients lacking decisional capacity. Without explicit documentation otherwise, the default in most hospitals in the United States has been to administer life-prolonging care that physicians often consider overly burdensome and unbeneficial [1]. ACP gained momentum following the Patient Self Determination Act of 1990 [2–4] to provide patients the right to decide ahead of time the type of life-sustaining measures they would want, or not, should they become incapable of communicating their end-of-life (EoL) care wishes.

While ACP has been embraced by clinicians, patients, researchers [5–10] and the Centers for Medicare & Medicaid Services [11] as an indicator of high quality EoL care, it has also been derided by leaders in palliative medicine. Morrison et al. [12] have asserted that ACP is an ineffective instrument for ensuring that dying patients receive value-concordant care near death, citing 2 comprehensive reviews which failed to find evidence linking ACP to patients’ receipt of goal-concordant EoL care [13, 14]. Similarly, in a 2022 New York Times essay, Lamas, a critical-care physician, questioned whether the current model of ACP works well enough to improve EoL care outcomes [15]. Other critical-care physicians and palliative care experts such as Curtis [5], have countered with examples, including quite poignantly his own, suggesting the comfort, preparation, and peace of mind that ACP affords. Consistent with this view, our own research has demonstrated that elements of ACP [16], such as engaging in EoL discussions [17, 18] and/or DNR order completion [19], are associated with patients’ receipt of fewer unbeneficial procedures [16–19], less perceived suffering and loss of dignity [19], and higher rates of patients’ receipt of value-concordant EoL care [18].

But perhaps not all aspects of ACP have equal impact on EoL outcomes. Surprisingly little is known of how elements of ACP, alone or in combination, relate to the odds that patients will receive EoL care aligned with their preferences. As noted above, using data from our Coping with Cancer 1 (CWC 1) study, we have found EoL discussions with physicians to be associated with patients’ increased likelihood of receiving value-concordant EoL care [18], but we still do not know how these discussions compare to DNR order completion and/or designation of a healthcare proxy (HCP) in terms of their associations with patients’ receipt of value-concordant EoL care. Identifying which ACP activities are most impactful, as well as the combinations of ACP activities associated with the highest rates of cancer patients’ receipt of value-concordant care, could inform recommended strategies for obtaining desired EoL care.

There is also reason to believe that patient preferences and priorities not only influence the intensity of the care received near death [20], but also the likelihood of receipt of care consistent with those preferences [18]. For example, an analysis of 301 patients with advanced cancer recruited in CWC 1 found that the 27.6% who reported preferring life-extending therapy, regardless of the discomfort imposed by such care, were nearly 3 times more likely to receive intensive care and over 2 times less likely to receive hospice care than patients with a preference for EoL care focused on alleviation of pain and discomfort [20]. Another report using the same dataset found that 68% of patients received EoL care consistent with the care preferences that they had reported in a baseline assessment, but that rates varied dramatically based on the patient’s EoL treatment preferences. For example, 59% of patients who stated that they preferred EoL care prioritizing relieving pain and discomfort then avoided life-extension treatment, but only 9% who prioritized life-prolonging treatment received it [18]. In light of these results, a significant question that remains is whether the ACP activities associated with receipt of value-concordant care would differ based on the patient’s stated EoL care preferences.

Rather than lump ACP activities together as a single entity, our aim in this study is to examine the ACP activities associated with the greatest proportions of patients receiving care consistent with their reported EoL care preferences compared to not engaging in these ACP activities. Using a sample of 278 patients with advanced cancer recruited in CWC 1, as well as in a follow-up study, Coping with Cancer 3 (CWC 3), we sought to determine and compare the ACP activities, alone and in combination, associated with the highest likelihood of receipt of value-concordant EoL care. We then stratified analyses based on the patient’s self-reported EoL care-related priorities. Based on prior findings [17–19], we expected that EoL discussions with physicians and DNR order completion would be associated with increased likelihood of patients receiving value-concordant EoL care compared to not engaging in any of the examined ACP activities. Consistent with prior results [18] we also hypothesized that ACP activities would have a greater effect on the receipt of value-concordant EoL care for patients with a stated preference for care prioritizing comfort compared to life-prolongation.

Methods

Sample

Study participants were enrolled in CWC 1 (CA106370) and CWC 3 (MD007652)– 2 multisite, prospective, longitudinal cohort studies of terminally ill cancer patients funded by the National Institutes of Health. Patients were eligible to participate in these studies if they were adults (at least 20 years old for CWC 1 and at least 21 years old for CWC 3) and had metastatic cancer refractory to 1st-line chemotherapy (or, for some CWC 3 participants with specific cancers, locally advanced cancer and/or disease progression on at least 2 lines of chemotherapy). Patients were ineligible to participate if they were not fluent in English or Spanish, displayed cognitive impairment as measured by a score of less than 6 on the Short Portable Mental Status Questionnaire, were unable to identify an informal caregiver, were enrolled in hospice or receiving palliative care, or were judged by interviewers or clinical staff as lacking stamina to participate in study activities.

Patients in CWC 1 were recruited from September 2002 through February 2008 from Yale Cancer Center (New Haven, CT), the Veterans Affairs Connecticut Healthcare System Comprehensive Cancer Clinics (West Haven, CT), Parkland Hospital (Dallas, TX), Simmons Comprehensive Cancer Center (Dallas, TX), Massachusetts General Hospital (Boston, MA), Dana-Farber Cancer Institute (Boston, MA), and New Hampshire Oncology-Hematology (Hookset, NH). Patients in CWC 3 were recruited from November 2015 through May 2019 from Memorial Sloan-Kettering Cancer Center (New York, NY), Columbia University Medical Center (New York, NY), Northwestern University Robert H. Lurie Comprehensive Cancer Center (Chicago, IL), Rush University Medical Center (Chicago, IL), University of Texas-Southwestern (Dallas, TX), University of Texas at El Paso (El Paso, TX), and University of Miami Health System (Miami, FL). Institutional review board approval was obtained at all study sites, including Weill Cornell Medicine, which served as the single Institutional Review Board of record for CWC 3. Written informed consent was provided by all study participants.

CWC 1 and CWC 3 participants were included in this analysis if they died during the study period and had complete data on demographic characteristics, EoL treatment preferences, ACP, and life-extending care they received at the EoL. This produced a sample of 311, but 33 of these patients declined to choose between 2 care priorities, yielding an analytic sample of 278.

Protocol

Data were collected via an in-person baseline interview with the patient and a post-mortem interview conducted with persons most familiar with the patient’s care at that time. In CWC 3, post-mortem interviews were conducted with 1 of the patient’s informal caregivers. In CWC 1, post-mortem interviews were conducted with either the patient’s informal caregiver or medical staff (e.g., hospice nurse) who last cared for the patient in addition to abstracting relevant information from the patient’s medical records. Patients in our sample died a median 111 days after baseline interview (IQR 59 to 216 days). Postmortem assessments occurred a median of 24 days after patient death (IQR 7 to 64 days).

Measures

Treatment preferences

At baseline, patients were asked “if you could choose, would you prefer (1) a course of treatment that focused on extending life as much as possible, even if that meant more pain and discomfort, or (2) a plan of care that focused on relieving pain and discomfort, even if that meant not living as long?” As noted in other CWC analyses utilizing this methodology [18], this question was initially used in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT trial) [21].

EoL care

Use of mechanical ventilation, cardiopulmonary resuscitation, tube feeding, chemotherapy, and/or treatment in an intensive care unit (ICU) during the patient’s last week of life were collected through the post-mortem interview. Use of any of these interventions in the last week of life was used to create a dichotomous variable indexing life-extending care. Use of inpatient or outpatient hospice for at least one week was used to create a dichotomous variable indicating receipt of hospice care.

Value-concordant EoL care

Patients who reported a desire for life-extending care at baseline and who received life-extending care were coded as receiving value-concordant care, as were patients who reported a desire for care that prioritized comfort and who avoided life-extending care. Patients who were mismatched on baseline treatment preferences and EoL care were coded as not receiving value-concordant care–a method used in prior published analyses of CWC data [18]. This dichotomous variable served as the primary outcome. We also operationalized value-concordant care using hospice to indicate comfort-focused care at the EoL. Here patients who prioritized life-extending care and did not receive at least one week of hospice care, as well as patients who prioritized comfort-focused care and did receive at least one week of hospice care, were coded as receiving value-concordant care. Those who were mismatched on hospice utilization and baseline treatment preferences were coded as not receiving value-concordant care.

ACP

Patients reported at baseline interview whether they had (1) engaged in a discussion with their doctor about their EoL care priorities, (2) completed a DNR order, and (3) completed HCP/durable power of attorney documentation. We focused on these 3 elements because we consider them to be the most impactful and common; we excluded living wills as they were highly collinear with DNR order completion, are less common, and likely less impactful compared to DNR orders. These variables were used in 4 ways: they were examined independently, used to create an 8-level categorical variable of all their possible combinations, used to create a dichotomous variable of any versus no ACP, and used to create a dichotomous variable of all ACP elements at once versus no or any other ACP combination.

Demographic data

Patients’ self-reported age, sex, race, and ethnicity were obtained in baseline interviews.

Analysis

First, we described differences in demographic characteristics and treatment preferences among patients with any versus no ACP using frequencies, percentages, and chi-squared tests for categorical variables and medians, interquartile ranges, and Wilcoxon rank sum tests for continuous variables. We also compared the CWC 1 and CWC 3 cohorts on treatment preferences. Then, we used stabilized inverse propensity scores to weight the data and account for potential confounding due to sample characteristics. Weights were assigned using non-parametric covariate balancing propensity scores with age, sex, race, ethnicity, and EoL treatment preference used as predictors for a dichotomous variable of any versus no ACP. Standardized mean differences (SMD) were used to assess covariate balance before and after weighting, and a SMD <0.10 post-weighting was considered to represent acceptable balance between groups [22].

Next, we used weighted frequencies, percentages, and bivariate logistic regression models to compare the proportion of patients who received value-concordant care by 1) any versus no ACP and 2) all possible combinations of ACP elements. We then stratified our sample by EoL treatment preference and used weighted frequencies, percentages, and chi-square tests with Rao and Scott’s correction to examine each ACP element separately and in aggregate, assessing the odds of receiving value-concordant care by type of ACP among each preference group. For each comparison in this stratified analysis, the data were reweighted using the same methodology as above. Lastly, we repeated our analyses using a definition of value-concordant care based on hospice utilization. All analyses were completed using R 4.1.1. Two-sided tests were used with p<0.05 taken to be statistically significant.

Results

Demographic characteristics and treatment preferences of the sample used in this analysis can be found in Table 1. This sample included 243 participants from CWC 1 and 35 participants from CWC 3. Baseline treatment preferences between cohorts were similar; 183/243 (75%) of participants in CWC 1 and 26/35 (74%) of participants in CWC 3 expressed a preference for comfort-focused EoL care, with the remaining participants in each cohort expressing a preference for life-extending care. Following initial weighting, the sample was balanced at a SMD <0.10 level on all observed covariates (Fig 1).

Table 1. Demographic characteristics and treatment preferences of unweighted sample (N = 278).

Characteristic No ACP, N = 801 Any ACP, N = 1981 p2
Age 56 (47, 67) 62 (54, 70) 0.003
Gender 0.632
    Male 40 (50%) 107 (54%)
    Female 40 (50%) 91 (46%)
Race <0.001
    White 34 (42%) 139 (70%)
    Black 18 (22%) 36 (18%)
    Other 28 (35%) 23 (12%)
Ethnicity <0.001
    Not Hispanic 54 (68%) 174 (88%)
    Hispanic 26 (32%) 24 (12%)
Treatment preferences 0.083
    Extending life 26 (32%) 43 (22%)
    Relieving pain 54 (68%) 155 (78%)
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1Median (IQR); n (%)

2Wilcoxon rank sum test; Pearson’s Chi-squared test

Note: ACP = advance care planning

Fig 1. Displays the absolute standard mean differences in sociodemographic characteristics of the sample depending on whether they had engaged in any of the examined aspects of advance care planning (ACP) or not.

Fig 1

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On the left, green indicates the differences on sociodemographic characteristics after weighting. On the right, red indicates the differences before weighting. The figure shows that weighting effectively neutralized differences on these sociodemographic characteristics.

Proportions of value-concordant care were similar among patients who engaged in any ACP compared to those who did not (71% versus 64%, OR = 1.37, 95% CI = 0.75–2.51, p = 0.303) (Table 2). The combination of ACP elements associated with the largest proportion of value-concordant care was DNR, HCP, and EoL discussions with physicians together (i.e., all possible ACP elements at once) (44/50, 87%) (Table 2). Patients who completed these 3 ACP elements were significantly more likely to receive value-concordant care than patients who did not engage in ACP (OR = 3.91, 95% CI = 1.50–10.2, p = 0.006). The combination of ACP elements associated with the smallest proportion of value-concordant care was HCP only (15/31, 50%).

Table 2. Odds of receiving value-concordant care by type of ACP (N = 278).

Type of ACP Weighted proportion receiving value-concordant care OR 95% CI p
Any versus no ACP
    No ACP 51/80 (64%) — —
    Any ACP 140/198 (71%) 1.37 0.75, 2.51 0.303
By ACP element
    No ACP 51/80 (64%) — —
    EoL discussions with physicians, DNR, and HCP 44/50 (87%) 3.91 1.50, 10.2 0.006
    EoL discussions with physicians and DNR 14/18 (77%) 1.93 0.55, 6.80 0.304
    DNR 10/14 (76%) 1.77 0.42, 7.38 0.435
    EoL discussions with physicians 25/34 (74%) 1.60 0.58, 4.44 0.363
    HCP and DNR 19/31 (62%) 0.95 0.39, 2.29 0.900
    EoL discussions with physicians and HCP 12/20 (59%) 0.83 0.30, 2.35 0.730
    HCP 15/31 (50%) 0.56 0.22, 1.41 0.219
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Data weighted for any versus no ACP using stabilized inverse propensity score weights

Note: EoL = end of life, HCP = health care proxy, DNR = do-not-resuscitate order

For each comparison in Table 3, the sample was re-weighted and remained balanced at a SMD <0.10 level on all observed covariates. Among patients who desired comfort-focused care, those who discussed EoL care preferences with their physician more frequently received value-concordant care than those who did not (88% versus 74%, p = 0.013). Having a DNR was significantly associated with more frequent receipt of value concordant care among those who desired comfort-focused care (89% versus 75%, p = 0.005) but not among those who desired life-extending care (33% versus 27%, p = 0.666). Among patients who desired life-extending care, those who engaged in any form of ACP received value-concordant care almost as frequently as those who did not (30% versus 32%, p = 0.880). Utilizing all observed ACP elements was associated with increased frequency of value-concordant care, both among patients who prioritized comfort (95% versus 77%, p = 0.002) and in a small, non-statistically significant set of observations among those who prioritized extending life (30% versus 25%, p = 0.848).

Table 3. Weighted proportion of patients receiving value-concordant care by treatment preference and type of advance care planning (N = 278).

Extending life Relieving pain/discomfort
Type of ACP Weighted proportion receiving value-concordant care p Weighted proportion receiving value-concordant care p
EoL discussions with physicians 0.993 0.013
    No 11/38 (28%) 87/118 (74%)
    Yes 8/31 (28%) 80/91 (88%)
DNR 0.666 0.005
    No 11/39 (27%) 90/121 (75%)
    Yes 10/29 (33%) 79/89 (89%)
HCP 0.722 0.964
    No 10/34 (29%) 84/104 (81%)
    Yes 12/35 (34%) 85/105 (81%)
Any ACP 0.880 0.129
    No 6/20 (32%) 45/60 (74%)
    Yes 15/49 (30%) 125/149 (84%)
All ACP 0.848 0.002
    No 14/55 (25%) 130/168 (77%)
    Yes 4/14 (30%) 39/41 (95%)
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Data reweighted using stabilized inverse propensity score weights for each comparison

In analyses examining value-concordant care as defined by hospice utilization (N = 275) (Note: 3 participants had missing data on hospice utilization), ACP element combinations that involved EoL discussions with physicians had the largest proportions of value-concordant care (Table 4). Among patients prioritizing comfort-focused care, EoL discussions and utilizing all ACP elements remained significantly associated with improved odds of value-concordant care, but DNR was not (Table 5). Among patients who prioritized life-extending care, those who did not engage in any ACP trended towards more frequently receiving value-concordant care (61% versus 37%, p = 0.073).

Table 4. Odds of receiving value-concordant care by type of ACP using hospice for at least one week as sole indicator of value-concordant care (N = 275).

Type of ACP Weighted proportion receiving value-concordant care OR1 95% CI1 p
Any versus no ACP
    No ACP 44/79 (56%) — —
    Any ACP 123/196 (63%) 1.30 0.71, 2.38 0.386
By ACP element
No ACP 44/79 (56%) — —
    EoL discussions with physicians and DNR 13/17 (78%) 2.83 0.71, 11.3 0.140
    EoL discussions with physicians and HCP 13/19 (69%) 1.72 0.57, 5.19 0.333
    EoL discussions with physicians, DNR, and HCP 34/50 (67%) 1.57 0.72, 3.40 0.252
    EoL discussions with physicians 22/34 (63%) 1.34 0.52, 3.47 0.550
    HCP and DNR 18/31 (59%) 1.10 0.46, 2.63 0.831
    DNR 8/14 (57%) 1.05 0.29, 3.81 0.944
    HCP 15/31 (49%) 0.74 0.29, 1.86 0.521
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1OR = Odds Ratio, CI = Confidence Interval

Data weighted for any versus no ACP using stabilized inverse propensity score weights

Table 5. Weighted proportion of patients receiving value-concordant care by treatment preference and type of advance care planning, using hospice for at least one week as sole indicator of value-concordant care (N = 275).

Extending life Relieving pain/discomfort
Type of ACP Weighted proportion receiving value-concordant care p Weighted proportion receiving value-concordant care p
EoL discussions with physicians 0.062 0.002
    No 21/38 (54%) 64/117 (55%)
    Yes 9/31 (28%) 69/89 (77%)
DNR 0.274 0.120
    No 20/39 (52%) 72/118 (61%)
    Yes 11/29 (36%) 63/88 (72%)
HCP 0.267 0.590
    No 18/34 (51%) 69/101 (68%)
    Yes 12/35 (35%) 74/104 (71%)
Any ACP 0.073 0.053
    No 12/20 (61%) 32/59 (55%)
    Yes 18/49 (37%) 105/147 (71%)
All ACP 0.035 0.021
    No 27/55 (49%) 105/165 (64%)
    Yes 0/14 (0%) 34/41 (83%)
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Discussion

Morrison et al. [12] conclude that ACP is not associated with better EoL outcomes overall, and specifically with respect to increased rates of patient receipt of value-concordant care. But, to date, the debate about the effectiveness of ACP on EoL outcomes has lacked granularity. We here examined specific elements of ACP that may or may not, alone or in combination, promote receipt of value-concordant EoL care, and for whom, based on patients’ self-reported EoL care preferences. These results suggest that there may be effective ways for patients to engage in ACP and receive value-concordant care if they prioritize comfort, but that ACP is not helpful to promoting value-concordant care for patients who prioritize life-prolongation.

Our results revealed that the combination of ACP elements most associated with EoL care consistent with patient preferences included DNR order completion, designation of an HCP, and engaging in EoL discussions with physicians. It is unsurprising that the more elements of ACP completed, the more likely patients will receive value-concordant care. Still, it appears remarkable that almost 90% of patients who engaged in EoL discussions, signed a DNR order, and assigned an HCP– 3 activities—received EoL care aligned with their baseline reported care preferences. These results are consistent with our prior research suggesting that EoL discussions are associated with a greater likelihood of receiving value-concordant care [18]. As another example, prior research also found that DNR order completion within the first 48 hours of an ICU admission was associated with receipt of fewer aggressive medical interventions and less suffering, though not explicitly value-concordant care [19]. Taken together, our results add to the literature demonstrating that ACP activities are potentially effective tools for supporting patients’ receipt of EoL care consistent with their values.

That said, all ACP activities may not be equally effective, and their efficacy may vary depending on patients’ baseline reported preferences for EoL care. We learned that among the studied advanced cancer patients who prioritized comfort-focused care at the EoL (which was the clear majority, 67%), engaging in EoL discussions with their physician and completion of DNR orders were both significantly associated with receipt of value-concordant EoL care. For those who engaged in all 3 of the examined ACP activities, 95% received value-concordant care. Further, when hospice care was used to indicate receipt of comfort-focused care at EoL, we found that EoL discussions with physicians was the sole individual ACP element significantly associated with receipt of value-concordant care among patients prioritizing comfort at the EoL. Thus, our results suggest that while there may be multiple pathways to avoiding intensive EoL care through ACP, EoL discussions with physicians may have unique potential for achieving hospice utilization among those prioritizing the alleviation of discomfort near death.

Importantly, we also found that for advanced cancer patients who indicated that they would prioritize life-extension to comfort at the EoL, no individual ACP activity had a significant association with odds that they would get the life-extending care that they expressed preferring in the baseline interview. It appears that the healthcare system is structured to preserve and prolong life as the default, and that patients who desire that form of EoL care will likely get it without any ACP intervention. If anything, for those wishing to avoid hospice care, ACP may prove counterproductive. That said, from the perspective of a family surrogate decision-maker, engaging in EoL discussions to clarify the patient’s prioritization of life-extending care may well promote the patient’s receipt of that type of EoL care in the not uncommon circumstance in which the patient becomes incapacitated prior to death.

While we had expected HCP designation to be influential, our results suggest that HCPs alone are not effective for ensuring that patients who prioritize comfort will receive value-consistent EoL care. There are several potential explanations for this finding, including that patients and their HCPs may have conflicting preferences regarding EoL care and that HCPs do not necessarily ensure that the patient’s, rather than their own, preferences will be honored. It may also be true that HCPs are unaware of the patient’s priorities and/or that patient priorities may change from what they told the HCP and/or that the medical team may not be influenced by the HCP if they believe the HCP is not well-informed or acting in the best interest of the patient. Regardless of the reason, these results suggest that patients, HCPs, and oncologists should engage in EoL discussions so that all may be informed of the benefits and harms of the treatment options being presented to them and work to realize that the patient’s informed wishes and priorities are respected.

Our study findings should be considered in the context of its limitations. Although our sample size was sufficient to demonstrate statistically significant differences in achieving value-concordant care, a larger sample would afford greater statistical power to test for subgroup effects. In addition, the EoL discussions only documented discussions between patients and their physicians, and not with other member of the care team (e.g., advance practice providers who can also bill for these discussions) or their family surrogate decision-maker. Future research should replicate these findings in larger and more diverse patient samples, including non-cancer patients, and inquire about EoL discussions with other clinical staff and family members. It is important to acknowledge that a key limitation of the present analysis is that EoL care priorities reported in a baseline interview may well have changed as patients approached death and thus our analysis may have misclassified instances of goal-concordant care. Additionally, our measure of EoL care with which we matched the baseline EoL care preferences was limited to care received in the final week of life. Future research should examine the effectiveness of other elements of ACP (e.g., living wills), patient care preferences closer to death, as well as include care received in the weeks leading up to the patient’s final week. This report did not examine the role of trusting and empathic relationships with a professional/s which has been shown to be a key motivator for engaging individuals and families in ACP discussions [23–25]. Lastly, it is important to acknowledge that much of the sample was assessed in a study conducted in well over a decade ago. Given the changing landscape of ACP, the results may no longer hold and need to be confirmed in a more recently conducted study.

Conclusion

Data from two prospective, longitudinal studies were used to examine which elements of ACP were associated with the greatest likelihood of receiving value-concordant EoL care. We found that for patients who prioritized comfort, EoL discussions with physicians and completion of DNR orders were associated with significantly greater odds of receiving value-concordant EoL care. For patients who prioritized life-extension, ACP did not appear to improve odds of receiving value-concordant EoL care and may even reduce them. Results suggest the most effective forms of ACP to promote value-concordant EoL care based on patient priorities.

Data Availability

All relevant data are within the paper.

Funding Statement

: This research was supported, in part, by the following grants from the National Institute of Health: R01 MH63892 (HGP) from the National Institute of Mental Health, R01 CA106370 (HGP) from the National Cancer Institute; R01 MD007652 (PKM, HGP) from the National Institute on Minority Health and Health Disparities; R35 CA197730 (HGP) from the National Cancer Institute; and UL1 TR002384 (Weill Cornell Medicine CTSC) from the National Center for Advancing Translational Sciences, from the National Institute on Aging-funded K99 grant (K99 AG073509). Dr. Prigerson, Dr. Maciejewski, and Dr. Falzarano have received NIH funding that supports some of their research effort The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Cari Malcolm

Transfer Alert

This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present.

20 Sep 2022

PONE-D-22-15436Advance Care Planning to Promote Cancer Patients’ Receipt of Value-Concordant CarePLOS ONE

Dear Professor Prigerson,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript has been evaluated by two reviewers, and their comments are available below. I, as Academic Editor, acted as one of the reviewers as this topic lies within my area of research and expertise. 

The reviewers have raised a number of concerns that need attention largely around interpretations of this study's findings and communicating its limitations. 

Could you please revise the manuscript to carefully address the concerns raised?

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We look forward to receiving your revised manuscript.

Kind regards,

Cari Malcolm

Academic Editor

PLOS ONE

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2. In ethics statement in the manuscript and in the online submission form, please provide additional information about the patient records/samples used in your retrospective study. Specifically, please ensure that you have discussed whether all data/samples were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data/samples from their medical records used in research, please include this information.

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When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

4. Thank you for stating the following in the Acknowledgments Section of your manuscript: 

This research was supported, in part, by the following grants from the National Institute of Health: R01 MH63892 (HGP) from the National Institute of Mental Health, R01 CA106370 (HGP) from the National Cancer Institute; R01 MD007652 (PKM, HGP) from the National Institute on Minority Health and Health Disparities; R35 CA197730 (HGP) from the National Cancer Institute; and UL1 TR002384 (Weill Cornell Medicine CTSC) from the National Center for Advancing Translational Sciences, from the National Institute on Aging-funded K99 grant (K99 AG073509).

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. 

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: 

NO The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

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6. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well. 

7. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

8. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is an important analysis of that includes consideration of patient preferences and assesses goal concordance with outcomes, offering a more granular look at the influence of ACP and its included elements.

The manuscript is well-written and also speaks to the current controversy over the value and utility of ACP. There are some areas of clarity for consideration included below. Further, while the statistical methods appear appropriate, it would be best for a statistician to review the specific analyses described.

The authors include 3 components of ACP – EoL discussions with a physician, completion of a DNR, and identification of a proxy. There are some potential limitations with this structure that should be addressed. First, if this only includes EoL discussions with a physician, there may be important EoL discussions with other qualified clinical care providers that are missed (for example, advanced practice practitioners can also bill for ACP). But more importantly, are the three categories truly separate and without overlap- for example, is completing a DNR truly distinct from EoL discussion? It seems reasonable that some of these discussions might include a review of DNR status and decision-making, as well as who a patient might select as a proxy.

From the original study protocol- why exclude patients with terminal cancer if receiving palliative care? Wouldn’t this be clinically appropriate for many of these patients?

This paper does briefly note an important limitation in the discussion – the analysis assumes patient preferences remain stable from baseline measure to outcomes to assess goal concordance – and these preferences could change after the median 111 days.

It appears, although is not completely clear, that all ACP measures are exclusively collected at the baseline interview. Could a participant have engaged in or changed any of the elements noted at baseline prior to death that are not captured in the data (or indicated ‘no DNR’ at baseline but later had one? Is it possible to check for, for ex., updated DNR status along with the outcome data?) Reviews of EoL preference stability shows a range of variability across studies, although generally are more stable for seriously ill patients.

It would be helpful to include more discussion of implications for patients prioritizing life extending care. What are recommendations for this group?

Reviewer #2: This is a very well written paper communicating novel research around the complex issue of promoting value-concordant care in people with cancer through the use of advance care planning (ACP).

The introduction/background section is excellent and, importantly, highlights recent controversies and debate around the utility of and challenges around ACP. Key and recent evidence is integrated throughout this section, leading to the authors’ hypotheses.

The methods are detailed and clearly communicated.

Given that data/participants from two studies (CWC1 and CWC3) and therefore time periods (CWC1 2002-2008 and CWC2 2015-2019) were used in this retrospective analysis and cognisant of the fact that the landscape of ACP and value-concordant care has changed and evolved considerably over the nearly 20 years since 2002, this needs to be acknowledged by the authors and explicitly discussed in the limitations section. I would also like to see greater transparency around how comparable data from CWC1 and CWC2 participants were in terms of, particularly, treatment preferences. The 278 participants are communicated as a whole sample in table 1 so it isn’t clear.

An additional limitation which needs to be addressed is around the inclusion of solely end of life care discussions with a physician. It is more than often the case that there is overlap and ongoing supportive discussions from a range of professionals, the family/significant others and the patient that lead to the patient’s decision around treatment preferences. There is also a growing body of evidence that having trusting and empathic relationships with a professional/s is a key motivator for engaging individuals and families in ACP discussions. The current study isn’t able to tease that out and therefore needs to acknowledge that. It may be worth referring to the following recent article in the discussion:

Rosa WE, Izumi S, Sullivan D, Lakin J, Rosenberg AR, Creutzfeldt CJ, Lafond D et al. Advance Care Planning in Serious Illness: A Narrative Review. Journal of Pain and Symptom Management. 2022 Aug 24 https://doi.org/10.1016/j.jpainsymman.2022.08.012

Finally, the fact that retrospective analysis is based around the patient’s preferences for end of life care to stay the same in the last weeks and months of life is a considerable limitation of this research and the findings and conclusions need to be interpreted with some caution. There needs to be greater transparency around this and it needs to be explicitly stated.

**********

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2023 Jan 11;18(1):e0280197. doi: 10.1371/journal.pone.0280197.r002

Author response to Decision Letter 0

1 Dec 2022

Comment #1:

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone

/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: We have made our manuscript compliant with PLOS ONE formatting.

2. In ethics statement in the manuscript and in the online submission form, please provide additional information about the patient records/samples used in your retrospective study. Specifically, please ensure that you have discussed whether all data/samples were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data/samples from their medical records used in research, please include this information.

Response: As stated in the manuscript, we obtained written informed consent from all study participants to have their data, including from their medical records, used in the study.

The following is now input into the online Ethics Statement: All participating institutions obtained IRB approval; Weill Cornell Medicine protocol #1312014603 was the IRB of record. Written informed consent was obtained from all study participants to have their data, including from their medical records, used in the study. The analysis for this specific study did not include data from the patient’s medical chart but rather from the postmortem interviews with the caregiver (professional or family member) who was most familiar with the care the patient had received in the last week of life. Data from the medical chart were used only as a validity check on the postmortem entries.

3. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

Response: We apologize for any inconsistencies. The grant information and funding information and financial disclosures sections should all match now.

4. Thank you for stating the following in the Acknowledgments Section of your manuscript:

This research was supported, in part, by the following grants from the National Institute of Health: R01 MH63892 (HGP) from the National Institute of Mental Health, R01 CA106370 (HGP) from the National Cancer Institute; R01 MD007652 (PKM, HGP) from the National Institute on Minority Health and Health Disparities; R35 CA197730 (HGP) from the National Cancer Institute; and UL1 TR002384 (Weill Cornell Medicine CTSC) from the National Center for Advancing Translational Sciences, from the National Institute on Aging-funded K99 grant (K99 AG073509).

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Response: We have removed funding information from the Acknowledgments Section, which itself has been deleted.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

NO The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Response: The following USA federal agencies supported the data collection and effort of the authors: R01 MH63892 (HGP) from the National Institute of Mental Health, R01 CA106370 (HGP) from the National Cancer Institute; R01 MD007652 (PKM, HGP) from the National Institute on Minority Health and Health Disparities; R35 CA197730 (HGP) from the National Cancer Institute; and UL1 TR002384 (Weill Cornell Medicine CTSC) from the National Center for Advancing Translational Sciences, from the National Institute on Aging-funded K99 grant (K99 AG073509).

While these National Institute of Health agencies financially supported the study, they did not influence the study design, data collection, analysis, interpretation of results or preparation of this or any other manuscript from these data and there is no apparent or real conflict of interest.

5. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Response: We will make the data used in this report available once we have published the data testing the hypotheses in the specified aims of the study. We will not provide these data prior to publication of the awarded study’s specific aims.

6. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

Response: We have stated that we obtained informed written consent for study participation. We now add the name of the IRB that reviewed and approved the CWC 3 was the Weill Cornell Medicine IRB. Weill Cornell Medicine was the IRB of record and required each participating site to obtain local IRB approval. All participating study sites obtained local IRB approval.

7. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files

Response: Tables and Figure 1 are now included within the main manuscript and not as separate files.

8. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response: We have added references recommended by the reviewers.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is an important analysis of that includes consideration of patient preferences and assesses goal concordance with outcomes, offering a more granular look at the influence of ACP and its included elements.

Response: We thank the reviewer for acknowledging that this analysis addresses an important, currently hotly contested debate regarding the value of ACP with respect to end-of-life outcomes.

The manuscript is well-written and also speaks to the current controversy over the value and utility of ACP. There are some areas of clarity for consideration included below. Further, while the statistical methods appear appropriate, it would be best for a statistician to review the specific analyses described.

The authors include 3 components of ACP – EoL discussions with a physician, completion of a DNR, and identification of a proxy. There are some potential limitations with this structure that should be addressed. First, if this only includes EoL discussions with a physician, there may be important EoL discussions with other qualified clinical care providers that are missed (for example, advanced practice practitioners can also bill for ACP). But more importantly, are the three categories truly separate and without overlap- for example, is completing a DNR truly distinct from EoL discussion? It seems reasonable that some of these discussions might include a review of DNR status and decision-making, as well as who a patient might select as a proxy.

Response: Thanks to the reviewer for noting the need to distinguish between patients’ discussions of the care they would want to receive if they were dying with their physician from other members of the care team who may also bill for these discussions (e.g., advance practice nurses). This is now acknowledged in the limitations section of the revised manuscript. With respect to overlap among the ACP components, it is worth noting that each aspect of ACP was assessed separately (e.g., DNR order completion, EoL discussions were coded separately) based on the patient’s perceptions and recall of what was discussed and documented. Future research that audio and/or video graphically records what was discussed and what was documented would help to distinguish between these components more objectively – a point we now note in the limitations section of the revised manuscript.

From the original study protocol- why exclude patients with terminal cancer if receiving palliative care? Wouldn’t this be clinically appropriate for many of these patients?

Response: We excluded advanced cancer patients who were receiving palliative care because that was an outcome we were predicting (i.e., we wanted to examine prospectively the factors that led to receipt of palliative care).

This paper does briefly note an important limitation in the discussion – the analysis assumes patient preferences remain stable from baseline measure to outcomes to assess goal concordance – and these preferences could change after the median 111 days.

It appears, although is not completely clear, that all ACP measures are exclusively collected at the baseline interview. Could a participant have engaged in or changed any of the elements noted at baseline prior to death that are not captured in the data (or indicated ‘no DNR’ at baseline but later had one? Is it possible to check for, for ex., updated DNR status along with the outcome data?) Reviews of EoL preference stability shows a range of variability across studies, although generally are more stable for seriously ill patients.

Response: As the reviewer notes, we acknowledge that patient preferences and ACP was assessed at baseline and that preferences and ACP activities could have occurred following that assessment. Results show, however, that regardless of what happened subsequent to the baseline assessment, the baseline assessed ACP activities did prove associated with EoL care received near death, highlighting that there was some influence regardless. It would be extraordinarily difficult to capture information on the interregnum for these deceased study participants at this point in time.

It would be helpful to include more discussion of implications for patients prioritizing life extending care. What are recommendations for this group?

Response: Results indicated that for patients prioritizing life-extending care there is less of a need for them to do anything as the system appears to be designed to provide life-extending care as the default. That said, it may be helpful for patients to engage in EoL discussions with the family surrogate decision-maker, who would ultimately make decisions regarding life-support should the patient become incapacitated. We now state this as follows in the revised Discussion:

“from the perspective of a family surrogate decision-maker, engaging in EoL discussions to clarify the patient’s preference for life-extending care may well promote the patient’s receipt of that type of EoL care in the not uncommon circumstance in which the patient becomes incapacitated prior to death.”

Reviewer #2: This is a very well written paper communicating novel research around the complex issue of promoting value-concordant care in people with cancer through the use of advance care planning (ACP).

The introduction/background section is excellent and, importantly, highlights recent controversies and debate around the utility of and challenges around ACP. Key and recent evidence is integrated throughout this section, leading to the authors’ hypotheses.

The methods are detailed and clearly communicated.

Given that data/participants from two studies (CWC1 and CWC3) and therefore time periods (CWC1 2002-2008 and CWC2 2015-2019) were used in this retrospective analysis and cognisant of the fact that the landscape of ACP and value-concordant care has changed and evolved considerably over the nearly 20 years since 2002, this needs to be acknowledged by the authors and explicitly discussed in the limitations section.

Response: We thank the reviewer for the appreciation of our work. We do wish to clarify that the analysis is prospective (i.e., the baseline assessment is associated with subsequent outcomes retrospectively reported by a caregiver in the postmortem assessment). We now note in the limitations section that some, but not all, of the data were obtained from a study conducted nearly 20 years ago and that given the changing landscape of ACP the results obtained may no longer hold and should be confirmed in a more recently conducted study.

I would also like to see greater transparency around how comparable data from CWC1 and CWC2 participants were in terms of, particularly, treatment preferences. The 278 participants are communicated as a whole sample in table 1 so it isn’t clear.

Response: Thank you for this comment. In the Results section, we now report the number of participants from each study cohort and treatment preferences by CWC 1 vs. CWC 3 as follows:

“This sample included 243 participants from CWC 1 and 35 participants from CWC 3. Baseline treatment preferences between cohorts were similar; 183/243 (75%) of participants in CWC 1 and 26/35 (74%) of participants in CWC 3 expressed a preference for comfort-focused EoL care, with the remaining participants in each cohort expressing a preference for life-extending care.”

An additional limitation which needs to be addressed is around the inclusion of solely end of life care discussions with a physician. It is more than often the case that there is overlap and ongoing supportive discussions from a range of professionals, the family/significant others and the patient that lead to the patient’s decision around treatment preferences. There is also a growing body of evidence that having trusting and empathic relationships with a professional/s is a key motivator for engaging individuals and families in ACP discussions. The current study isn’t able to tease that out and therefore needs to acknowledge that. It may be worth referring to the following recent article in the discussion:

Rosa WE, Izumi S, Sullivan D, Lakin J, Rosenberg AR, Creutzfeldt CJ, Lafond D et al. Advance Care Planning in Serious Illness: A Narrative Review. Journal of Pain and Symptom Management. 2022 Aug 24 https://doi.org/10.1016/j.jpainsymman.2022.08.012

Response: This is an excellent point. As noted in response to Reviewer 1, we have added the need to acknowledge that there may be important discussions with other, non-physician, members of the care team. We also have added a suggestion of the potential benefits of engaging in EoL discussions with a family surrogate. We now acknowledge the role of therapeutic bond with a member of the healthcare team as facilitating and supporting EoL discussions, citing Rosa et al., but also our prior research that highlights the influential role of the therapeutic alliance with a member of the care team in promoting ACP discussions.

Finally, the fact that retrospective analysis is based around the patient’s preferences for end of life care to stay the same in the last weeks and months of life is a considerable limitation of this research and the findings and conclusions need to be interpreted with some caution. There needs to be greater transparency around this and it needs to be explicitly stated.

Response: To clarify, the analysis was prospective and the baseline assessment of preferences were examined in relation to a subsequent (retrospective) postmortem assessment of the EoL care received. We have acknowledged that preferences may change as a limitation of this analysis. We now emphasize this as a key limitation.

________________________________________

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Response: Publishing the review is fine with us.

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Decision Letter 1

Cari Malcolm

22 Dec 2022

Advance Care Planning (ACP) to promote receipt of value-concordant care: Results vary according to patient priorities

PONE-D-22-15436R1

Dear Dr. Prigerson,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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Reviewer #2: Yes

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Reviewer #1: a very minor final revision prior to publication - the revised section of the final paragraph in the discussion "not with other member of the care team" should state "not with other members of the care team"

Reviewer #2: Thank you for submitting your revised manuscript. I am satisfied that all recommendations have been considered and the current version is suitable for publication.

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Reviewer #1: Yes: Amanda Jane Reich

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Acceptance letter

Cari Malcolm

3 Jan 2023

PONE-D-22-15436R1

Advance Care Planning (ACP) to promote receipt of value-concordant care: Results vary according to patient priorities

Dear Dr. Prigerson:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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