Trajectories of Goals of Care Among Patients With Advanced Cancer in the Last Two Years of Life.

CONTEXT: Patients with advanced cancer face evolving trade-offs between life extension, symptom relief, and financial burden. However, little is known about how these priorities change over time and how financial concerns intersect clinical goals near the end of life. OBJECTIVES: To identify distinct longitudinal trajectories of end-of-life care preferences and examine patient characteristics associated with these trajectories. METHODS: We analyzed data from 316 decedents with stage IV solid tumors enrolled in Singapore's COMPASS cohort during their last two years of life. At repeated assessments, patients rated two 9-point trade-offs: 1) life extension vs. symptom management, and 2) life extension vs. cost containment. Group-based trajectory modeling (GBTM) identified longitudinal patterns. Fixed-effects models assessed within-person changes in preferences over time, and multinomial logistic regressions examined predictors of trajectory membership. RESULTS: GBTM identified three distinct trajectories for both preference dimensions, with most patients (67.7%-76.3%) following balanced trajectories. Fixed-effects analyses revealed dimension-specific within-person changes. Among patients with balanced trajectories, symptom burden and hospice awareness were associated with shifts toward symptom-focused and cost-conscious preferences in both preference dimensions. In the symptom-focused trajectory, prognostic awareness and spiritual well-being were associated with less symptom-focused preferences. In the cost-containment-focused trajectory, hospice awareness was associated with stronger cost-conscious priorities. Age, sex, income level, and marital status predicted trajectory membership. CONCLUSION: Goals of care among patients with advanced cancer are largely dynamic, with distinct trajectories reflecting evolving trade-offs between survival, comfort, and cost. Recognizing these patterns can help clinicians anticipate shifting priorities and deliver timely, individualized, and value-concordant care.

Duke Scholars

Author Semra Ozdemir Population Health Sciences

Author Eric Andrew Finkelstein Population Health Sciences