# EHR-Based Advanced Care Planning and Late-Stage Cancer Treatment in a Middle-Income Country: A Retrospective Cohort Study

## TL;DR

This study examines end-of-life cancer care in Brazil, finding that documented advanced care planning in electronic health records is linked to less aggressive treatment near death.

## Contribution

The study introduces the use of EHR-based advanced care planning to reduce high-intensity end-of-life cancer treatments in middle-income countries.

## Key findings

- 19% of patients had documented ACP, which was associated with absence of late oncologic interventions.
- Younger age, higher education, and lower platelet count were linked to late-stage cancer treatments.
- Breast and lung cancers were the most common among patients who received end-of-life interventions.

## Abstract

Background: Cancer-directed treatment near the end of life may represent low-value, high-intensity care and potential medical futility, but data from middle-income countries are limited. This study used digitally documented advanced care planning (ACP) in the electronic health record (EHR) and indicators of late oncologic interventions (LOI) within 15 and 30 days before death to examine end-of-life care in Brazil. Objective: To identify factors associated with LOI near death and to explore whether documented ACP is linked to lower treatment intensity. Design: Retrospective cohort study. Setting/Participants: Adults with metastatic solid tumors who died between January 2022 and December 2023 in two oncology referral hospitals in southern Brazil and had ≥6 months of premortem EHR data. Measurements: LOI were defined as systemic anticancer therapy, radiotherapy, or oncologic surgery within 30 days (LOI-30) or 15 days (LOI-15) before death. Independent predictors were estimated by Poisson regression with robust variance. Results: Among 79 patients, 21.5% received LOI-30 and 8.9% received LOI-15. Breast and lung cancers were the most common primary sites. LOI-30 was independently associated with age < 60 years (relative risk [RR] 3.76; 95% confidence interval [CI] 1.50–9.44), higher education (RR 2.07; 95% CI 1.07–3.99), and lower platelet count (RR 0.96 per 10,000/µL; 95% CI 0.92–0.99). ACP was documented for 19% of patients and was associated with absence of LOI-30. Conclusions: Digitally visible ACP in the EHR was associated with reduced aggressive end-of-life care. Using existing EHR infrastructure to prompt and standardize ACP documentation may help align care with patient values in middle-income countries.