title: Influence of patients' preferences and treatment site on cancer patients' end-of-life care.
abstract: BACKGROUND
  Research suggests that patients' end-of-life (EOL) care is determined primarily by the medical resources available, and not by patient preferences. The authors examined whether patients' desire for life-extending therapy was associated with their EOL care.
  
  
  METHODS
  Coping with Cancer is a multisite, prospective, longitudinal study of patients with advanced cancer. Three hundred one patients were interviewed at baseline and followed until death, a median of 4.5 months later. Multivariate analyses examined the influence of patients' preferences and treatment site on whether patients received intensive care or hospice services in the final week of life.
  
  
  RESULTS
  Eighty-three of 301 patients (27.6%) with advanced cancer wanted life-extending therapy at baseline. Patients who understood that their disease was terminal or who reported having EOL discussions with their physicians were less likely to want life-extending care compared with others (23.4% vs 42.6% and 20.7% vs 44.4%, respectively; P≤.003). Patients who were treated at Yale Cancer Center received more intensive care (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.16-8.47) and less hospice services (OR, 0.52; 95% CI, 0.29-0.92) compared with patients who were treated at Parkland Hospital. However, in multivariate analyses that controlled for confounding influences, patients who preferred life-extending care were more likely to receive intensive care (adjusted OR [AOR], 2.91; 95% CI, 1.09-7.72) and were less likely to receive hospice services (AOR, 0.45; 95% CI, 0.26-0.78). Treatment site was not identified as a significant predictor of EOL care.
  
  
  CONCLUSIONS
  The treatment preferences of patients with advanced cancer may play a more important role in determining the intensity of medical care received at the EOL than previously recognized. Future research is needed to determine the mechanisms by which patients' preferences for care and treatment site interact to influence EOL care.
authors.affiliation: Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA. alexi_wright@dfci.harvard.edu
authors.forename: Alexi A
authors.initials: AA
authors.lastname: Wright
authors.forename: Jennifer W
authors.initials: JW
authors.lastname: Mack
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Kritek
authors.forename: Tracy A
authors.initials: TA
authors.lastname: Balboni
authors.forename: Anthony F
authors.initials: AF
authors.lastname: Massaro
authors.forename: Ursula A
authors.initials: UA
authors.lastname: Matulonis
authors.forename: Susan D
authors.initials: SD
authors.lastname: Block
authors.forename: Holly G
authors.initials: HG
authors.lastname: Prigerson
mesh_terms: D000368:Aged; D002173:Cancer Care Facilities; D005260:Female; D006738:Hospices; D006801:Humans; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000628:therapy*; D057240:Patient Preference; D010817:Physician-Patient Relations; D011446:Prospective Studies; D013727:Terminal Care