Advance Care Planning and Long-Term Bereavement in Caregivers of Patients With Metastatic Cancer

Advance care planning (ACP) may reduce bereaved caregivers' risk of complicated grief and anxiety, but evidence remains limited.

To examine associations between ACP engagement and caregivers' risk of complicated grief and anxiety six months after the patient's death, moderated by patient age and patient-caregiver relationship, and mediated by patient's emotional distress and caregiver preparedness for patient's death.

We used data from a prospective cohort of patients with Stage IV cancer and their primary caregivers, restricting analyses to 179 patients who died during follow-up. We assessed caregivers' risk of complicated grief using the Brief Grief Questionnaire, and anxiety with the anxiety subscale of the Hospital Anxiety and Depression Scale. Multivariable logistic and linear regression models were used, with interaction terms testing moderation by patient age and spousal relationship. Path analyses assessed indirect effects through caregiver perception of patients in the last week of life and preparedness for death.

ACP engagement was associated with lower odds of complicated grief risk (odds ratio [OR] = 0.36, 95% confidence interval [95% CI = [0.18, 0.72]), and lower anxiety symptoms (β = -1.18, 95% CI = [-2.28, -0.07]). These associations did not vary by patient age or patient-caregiver relationship. The combined indirect effect of ACP engagement on complicated grief through perceived patients' emotional distress and preparedness for death approached significance (β = -0.18 [95% CI, -0.39 to 0.03], P = 0.09).

ACP may benefit diverse groups of bereaved caregivers of patients with cancer. Larger studies should examine the mechanisms underlying ACP's influence on long-term bereavement.