title: The association between treatment preferences and trajectories of care at the end-of-life.
abstract: BACKGROUND
  Honoring patients' treatment preferences is a key component of high-quality end-of-life care.
  
  
  OBJECTIVE
  To determine the association of preferences with end-of-life care.
  
  
  METHODS
  Observational cohort study.
  
  
  METHODS
  118 community-dwelling persons age > or = 65 years with advanced disease who died in a study which prospectively assessed treatment preferences.
  
  
  METHODS
  End-of-life care was categorized according to four pathways: (1) relief of symptoms only, (2) limited attempt to reverse acute process with rapid change to symptomatic relief, (3) more intensive attempt to reverse acute process with eventual change to symptomatic relief, and (4) highly intensive attempt to reverse acute process with no change in goal.
  
  
  RESULTS
  Adjusting for diagnosis, those with greater willingness to undergo intensive treatment (defined as a desire for invasive therapies despite > or = 50% chance of death) were significantly more likely to receive care with an initial goal of life prolongation (pathways 2-4) [odds ratio 4.73 (95% confidence interval 1.39-16.08)] than those with lower willingness. Nonetheless, mismatches between preferences and pathways were frequent. Only 1 of 27 participants (4%) with lower willingness to undergo intensive treatment received highly intensive intervention (pathway 4); 53 of 91 participants (58%) with greater willingness to undergo intensive treatment received symptom control only (pathway 1).
  
  
  CONCLUSIONS
  The association between preferences and trajectories of end-of-life care suggests that preferences are used to guide treatment decision-making. In contrast to concerns that patients are receiving unwanted aggressive care, mismatches between preferences and trajectories were more frequently in the direction of patients receiving less aggressive care than they are willing to undergo.
authors.affiliation: Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: JoAnne Alissi
authors.initials: JA
authors.lastname: Cosgriff
authors.forename: Margaret
authors.initials: M
authors.lastname: Pisani
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
authors.forename: John R
authors.initials: JR
authors.lastname: O'Leary
authors.forename: Terri R
authors.initials: TR
authors.lastname: Fried
mesh_terms: D000203:Activities of Daily Living; D032722:Advance Care Planning; D000368:Aged; D000369:Aged, 80 and over; D019091:Critical Pathways; D003657:Decision Making; D005260:Female; D006333:Heart Failure / Q000628:therapy; D006801:Humans; D008297:Male; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D011379:Prognosis; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy; D013727:Terminal Care / Q000379:methods* / Q000458:organization & administration