Elders' environs and their end-of-life preferences.

HYPOTHESIS Elders' predilections regarding end-of-life interventions vary with their living environs. METHODS Patients in 3 settings--assisted living/outpatient, skilled nursing facility (SNF), and acute hospitalization--were asked to complete a brief questionnaire. RESULTS A total of 269 patients who averaged 80.0 ± (SD) 8.1 years, 44% male, 70% white were studied. Eighty-five patients were outpatient elderly, 101 were hospitalized for acute illnesses, and 83 were interviewed in SNFs. Outpatients (44/85; 52%) and acutely ill inpatients (40/101; 40%) were more likely than patients residing in SNFs (19/81; 23%) to choose comfort care only (P = .047) for acute pneumonia requiring endotracheal intubation (ETI). Overall, 32% changed their choice for ETI, opting for comfort care only if acute pneumonia was followed by disposition to an SNF. However, ambulatory and acutely ill elderly patients were 3 times as likely as SNF patients to change from aggressive to comfort care if the most likely outcome was disposition to an SNF (P < .001). In multivariate regression models, age (>80), gender, number of lost ADLs (>2), and self-described quality of life were not associated with choosing comfort care instead of ETI, whereas place of residence (SNF versus home) was independently associated with choosing ETI (odds ratio = 3.5; 95%CI = 1.9-6.4). Similarly, those already living in an SNF were more likely to opt for remaining there for advancing dementia (odds ratio = 7.7; 95%CI = 3.8-15.8). However, choices for ETI did not coincide with choosing an SNF for advancing dementia. CONCLUSIONS Elders residing in nursing homes were more likely than ambulatory patients to request invasive end-of-life care, a difference that was more pronounced when outcome required disposition to an SNF. These preferences were not dependent on patients' self-described disability or quality of life. This study suggests that qualitative outcomes matter to patients and their choices are associated with their place of residence.