Mixed perspectives on advance care planning between older patients with cancer and their family caregivers: a cross-sectional dyadic study

Family plays an important role in medical decision-making and advance care planning (ACP) in older individuals with cancer because of the complex medical care choices involved. The perceived pros and cons of ACP, as well as other ACP-related beliefs, can be discordant between patients and their family caregivers, leading to potential conflicts when physicians, family members, and patients want to initiate ACP. This study examined the perception patterns of families of older individuals with cancer regarding ACP-related values and beliefs and the pros and cons of ACP. Older individuals (aged > 60 years) with cancer and their accompanying primary family caregivers were invited to participate in interview- and self-administered questionnaires assessing their perceptions of ACP. Dyadic item-by-item responses were compared using intraclass correlation coefficients (ICCs). A multilevel latent class analysis was employed to identify perception patterns at both the family (higher) and individual (lower) levels. Of 644 eligible patient–caregiver dyads, 279 (43.3%) participated. The median age was 68.5 years (interquartile range [IQR], 64.1–73.4). The caregivers were primarily middle-aged (median age, 47.7 years), female (78%), and adult children (61%). Discomfort with future-focused discussions was common among patients (34.8%), whereas caregivers were worried about premature treatment withdrawal (33%). Latent class analysis revealed two family patterns: “Mixed perspectives” (72.2%), reflecting divergent views on ACP necessity, and the “ACP preferable” family pattern (27.8%), characterized by shared endorsement of ACP. Across families, the most commonly shared belief was that ACP was not yet necessary because patients decided day by day (ICC = 0.129; 95% CI, 0.011–0.244), although it was acknowledged as beneficial and proactive communication for the future (ICC = 0.155; 95% CI, 0.039–0.268). Across families, the most common belief was that ACP was premature, although it was recognized as beneficial for future care. These findings highlight the coexistence of readiness for and hesitation toward ACP among families of older individuals with cancer. The identified family patterns further emphasize the importance of tailoring interventions to accommodate differing levels of consensus and readiness within families.